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THE 


1} 


DISEASES  OF  THE  STOMACH^ 


BY 

t 

.  WILLIAM  W.  VAN  VALZAH,  A.M.,  M.D. 

PROFESSOR    OF    GENERAL    MEDICINE    AND     DISEASES     OF    THE     DIGESTIVE     SYSTEM     IN    THE 
NEW   YORK    POLYCLINIC   MEDICAL  SCHOOL   AND    HOSPITAL, 


J.   DOUGLAS   NISBET,  A.B.,  M.D. 

ADJUNCT     PROFESSOR     OF     GENERAL     MEDICINE     AND     DISEASES     OF    THE     DIGESTIVE     SYSTEM 
IN    THE    NEW    YORK    POLYCLINIC    MEDICAL    SCHOOL    AND    HOSPITAL. 


1Illustrate& 


PHILADELPHIA 
W.     B.     SAUNDERS 

925    WALNUT    STREET 


Coi'YRioiiT,  1898,  BY  W.  B.  Saundkrs. 


CONTENTS. 


SECTION  I.  PAGE 

Introduction  and  Classiptcation, 17 

SECTION   II. 

Diagnosis  and  Diagnostic  Methods, 21 

Chapter       I.   Clinical  History, 25 

Chapter      II.   The  Physical  Signs, 48 

Chapter    III.   The  Functional  Signs, 81 

1.  Secretion, 82 

(l)  The  Hydrochloric  Acid, 98 

(2|   The  Ferments, 119 

(3)   Mucus,  or  the  General  Secretion, 128 

2.  The  Motor  Function, 130 

3.  Absorption,      140 

4.  Digestive  Work, 141 

Chapter    IV.  The  Bacteriological  Signs,      142 

Chapter      V.   The  Anatomical  Signs, 158 

SECTION  III. 

General  Medication, 161 

Chapter       I.   Digestive  Hygiene,      162 

Chapter     II.  Diet,      165 

I.    Selection  of  a  Diet  in  Diseases  of  the  Stomach,      .    .  167 
II.    Signs  of  Correctness  of  the  Prescribed  Diet,  ....  223 

Chapter    HI.   Physical  Remedies, 227 

Chapter    IV.  Symptomatic  Treatment, 251 

Chapter      V.   Physiological  Treatment, 253 

Chapter    VI.   Bacteriological  Treatment, 258 

Chapter  VII.   Chemical  Treatment, 259 

SECTION  IV. 

The  Dynamic  Affections  of  the  Stomach, 262 

Chapter       I.  The  Sensory  Dynamic  Affections, 266 

I.    Bulimia, 266 

II.   Acoria, 269 

HI.    Parorexia, 270 

IV.    Anore.xia  Nervosa,      271 

V.   Gastralgia  Nervosa, 275 

VI.   Hyperesthesia  Gastrica, 281 

5 


6  CONTENTS. 

PAGIi 

Chai'TKR     II.    The  Dynamic  Affections  of  Secretion, 285 

1.  Adenohyperstlienia  Gastrica, 286 

(a)  Ilyperclilorhydria, 287 

(b)  Di<;;estive  Ilypercliylia  Clastrica, 295 

(c)  Paroxysmal  Ilypercliylia  (jastrica,      299 

2.  Adenasthenia  Gastrica, 301 

Chapter    III.   The  Motor  Dynamic  Affections, 304 

I.   Spasm  of  the  Cardia, 304 

II.   Spasm  of  the  I'ylorus, 31 1 

III.  Gastrospasm, 314 

IV.  Tormina  V'entriculi  Nervosa, 315 

V.   Kructatio  Nervosa, 316 

VI.    Habitual  Regurgitation, 321 

VII.    Rumination,  or  Merycism, 322 

VIII.  Nervous  Vomiting, 325 

I.   Symptomatic  Vomiting, 326 

2    Nervous  Vomiting 327 

IX.   Incontinence  of  the  I'ylorus, ^ii 

X.   Gastroplegia, 335 

Chatter    IV.  Neurasthenia  Gastrica, 336 

Chapter      V.   Myasthenia  Gastrica, 347 

1.  Myasthenia  with  Stagnation, 349 

2.  Myasthenia  with  Retention, 364 


SECTION  V. 
The  Anatomical  Dise.\ses  ok  the  Stomach, 378 

Chapter       I.  Gastritis, 378 

Acute  Gastritis, 378 

I.   Acute  Simple  Gastritis, 378 

II.   Mycotic  Gastritis, 382 

(a)  The  Fermentation  Form  of  Mycotic  Gastritis,  .  383 

(b)  Infectious  Forms,      386 

(1)  Purulent  Gastritis, 387 

(2)  Gastric  Fever, 389 

III.   Acute  Toxic  Gastritis, 391 

Chronic  Gastritis, 398 

I.  Gastritis  Catarrhalis  Chronica,  or  Chronic  Asthenic 

Gastritis 402 

II.   Gastritis  Glandularis  Proliferans,  or  Chronic  Hyper- 
sthenic Gastritis, 414 

III.   Gastritis  Glandularis  Atrophicans,  or  Atrophy  of  the 

Gastric  Glands, 430 

Chapter     II.   Ulcer  of  the  Stomach, 442 

Chapter    III.   The  Neoplasms  of  the  Stomach, 5^* 

Cancer  of  the  Stomach, 5*2 

Chapter     IV.   The  Displacements  of  the  Stomach, 554 

1.  Upward  Displacement 555 

2.  Vertical  or  Lateral  Displacement, 557 

3.  Gastroptosis, 5^4 

Chapter      V.   Obstruction  of  the  Orifices, 57^ 

1.  Obstruction  of  the  Cardia 577 

2.  Obstruciion  of  the  Pylorus, 5^4 


CONTENTS.  7 

SECTION  VI.  PAGE 

The  Vicious  Circles  of  the  Stomach,      6io 

Chapter       I.   Other  Organs  in  the  Diseases  of  the  Stomach,  or  the  Stomach 

in  the  Causation  of  Disease, 6lo 

I.    Influence  on  the  Intestines, 6il 

II.    Influence  on  the  Liver, 614 

III.  Influence  on  the  Blood, 615 

IV.  Influence  on  Nutrition,  .    ,    .    .         .         617 

V.    Influence  on  tlie  Heart  and  Circulation, 621 

VI.  Influence  on  the  Nervous  System, 624 

VII.   Influence  on  the  Skin, 629 

VIII.    Influence  on  the  Kidneys, 630 

Chapter     II.   The  Secondary  Diseases  of  the  Stomach, 631 

I.    Diseases  of  the  Intestines, 632 

II.    Diseases  of  the  Liver, 633 

III.  Diseases  of  the  Heart  and  Arteries, 634 

IV.  Diseases  of  the  Blood, 636 

V.    Diseases  of  Nutrition, 638 

VI.    Diseases  of  the  Kidneys, 639 

VII.  Spinal  Diseases, 640 

VIII.  Cerebral  Diseases, 641 

IX.    Diseases  of  the  Mouth,  Nose,  and  Throat, 643 

X.    Diseases  of  the  Respiratory  Organs, 645 

Index,     651 


DISEASES  OF  THE  STOMACH. 


SECTION    I. 
INTRODUCTION    AND    CLASSIFICATION. 


The  chief  excuse  for  the  existence  of  a  book  is  its  indi- 
viduality. While  it  is  true  that  the  definitive  features  of  a 
book  are  the  individual  views  of  the  author,  the  great  mass 
of  a  complete  work  on  the  diseases  of  the  stomach  must  con- 
sist of  the  results  of  research  gathered  all  along  the  course 
of  medical  history.  A  complete  book  on  this,  subject  for 
the  use  of  students  and  physicians  should  contain  what  of 
knowledge  there  is  of  practical  value  in  the  past,  what  of 
truth  there  is  in  the  literature  of  to-day,  and  what  of  informa- 
tion the  author  may  have  to  contribute.  An  outline  of  the 
evolution  of  our  knowledge  of  the  diseases  of  the  stomach 
would  be  a  just  tribute  to  the  original  workers  of  the  past. 
Possibly  narrow  and  individual  conceptions  should  be  rounded 
with  a  critical  estimate  and  statement  of  the  opinions  of  living 
authorities.  But  it  is  our  chief  endeavor  to  make  this  book 
simple,  clear,  practical,  and  complete  in  useful  information. 
We  have  consequently  decided  to  have  as  little  as  possible  to 
do  with  history,  to  omit  unnecessary  references  to  literature, 
and  to  rearrange  the  best  that  others  have  said  and  done  in 
unison  with  what  we  ourselves  have  learned  during  years  of 
special  study  and  practice. 

The  classification  of  the  diseases  of  the  stomach  should  be 
simple  and  practical,  and  embody  the  data  of  physiology  and 
pathology.  It  has  become  the  custom,  as  exemplified  in 
many  text-books,  to  describe  as  distinct  diseases  what  are  in 
reality  only  the  functional  signs  of  disease  or  what  are  merely 
inconstant  accompaniments.  Another  common  error,  in  our 
opinion,  is  the  mistaking  of  a  condition  for  a  disease.  It  will 
be   observed,   consequently,   that   separate   chapters   are   not 

17 


1 8  DISEASES  OF  THE  STOMACH. 

devoted  to  hyperchlorhydria,  to  hypochlorhydria,  to  anachlor- 
hydria,  to  acliylia,  to  gastrosuccorrhea,  to  erosions  of  the 
gastric  mucosa,  and  to  dilatation. 

The  abnormalities  of  secretion  have  been  classified  as 
chemical  types,  and  described  as  distinct  diseases  with  a  special 
causation,  special  evolution,  and  special  medication.  But 
these  abnormalities  of  secretion  are  signs  of  disease  and 
nothing  more, — be  the  disease  functional  or  be  it  organic. 
Tiie  secretory  signs  are  so  constant  and  characteristic  in  the 
various  anatomical  diseases  of  the  stomach  that  they  are  of 
very  great  positive  and  negative  ciiagnostic  value.  Hut  the 
abnormalities  of  secretion  may  not  depend  on  a  lesion  of  the 
mucous  membrane,  but  on  abnormal  glandular  activity,  which 
may  be  excessive  or  diminished.  These  two  dynamic  affec- 
tions of  secretion  we  describe  as  adenohypersthenia  gastrica 
and  adenasthenia  gastrica.  The  occurrence  of  achylia  as  a 
dynamic  affection  without  an  anatomical  lesion  of  the  mucous 
membrane  may  well  be  doubted,  for  adenasthenia  gastrica 
rarely,  and  then  only  temporarily,  advances  to  this  stage 
represented  by  complete  loss  of  glandular  power.  Achylia 
is  a  sign  of  the  terminal  period  of  asthenic  gastritis,  a 
symptom  of  atrophic  glandular  gastritis,  and  it  is  sometimes 
met  with  in  advanced  carcinoma. 

Gastrorrhea  was  first  described  minutely  by  Parker  (1838), 
although  the  condition  is  sometimes  known  as  Reichmann's 
disease  (1882).  This  symptom-group  may  occur  in  the 
course  of  chronic  glandular  (hypersthenic)  gastritis,  of  ob- 
struction to  the  evacuation  of  the  contents  of  the  stomach,  or 
of  myasthenia.  The  continuous  secretion  is  the  result  of  the 
retention  or  of  the  gastritis  or  of  both  ;  it  is  a  condition,  a  group 
of  signs  and  symptoms  which  may  develop  in  the  course  of 
well-known  diseases  of  the  stomach,  and  it  never  appears 
to  be  a  primary  disease. 

Erosions  of  the  gastric  mucosa  occur  in  acute  and  chronic, 
primary  and  secondary,  gastritis.  They  may  rarely  result 
from  cerebral  lesions,  but  are  then  ordinarily  insignificant. 
We  see  no  good  reasons  for  classifying  this  epiphenomenon 
as  a  distinct  disease  of  the  stomach. 

The  causes  of  so-called  "  dilatation  of  the  stomach  "  are 
obstruction  to  the  evacuation  of  the  contents  of  the  stomach 
into  the  intestines,  deformities  and  adhesions  of  the  stomach, 
displacements  of  the  stomach,  and  myasthenia  gastrica.  The 
condition  has  three  characteristics  :  the  stomach  has  become 
larger,  it  does  not  completely  empty  itself  during  the  twenty- 
four  hours,  and  it  does  not  retract  when   it  is  empty.     Some 


INTRODUCTION  AND  CLASSIFICATION.  1 9 

authors  regard  "  dilatation  of  the  stomach  "  as  synonymous 
with  enlargement  of  the  stomach  :  some  consider  the  presence 
of  food  in  the  stomach  in  the  early  morning  before  breakfast 
as  its  pathognomonic  sign  :  some  think  that  loss  of  tone  and 
elasticity  is  its  chief  characteristic.  The  normal  stomach  may 
be  large  or  small,  and  its  size  has  no  relation  to  its  motor 
sufficiency.  A  stomach  which  does  not  empty  itself  under  ordi- 
nary circumstances  during  the  twenty-four  hours,  may  be  large 
or  small,  strong  or  weak,  thick  or  thin.  A  stomach  which  has 
lost  its  tone  and  elasticity  and  its  power  to  retract  when 
empty  is  a  myasthenic  stomach.  We  shall  not  describe 
"  dilatation  "  as  a  disease;  and  we  deem  it  best  to  employ  the 
words  "  stagnation  "  and  "  retention  "  to  denote  the  degree  of 
motor  insufficiency,  and  to  emphasize  the  fact  that  motor 
insufficiency  is  a  functional  sign  and  not  a  morbid  entity. 
The  word  "  dilatation,"  like  the  word  "  dyspepsia,"  has  no 
precise  meaning,  and  embodies  false  notions.  These  words 
impede  medical  progress  and  should  become  obsolete. 

It  is  also  a  mistake,  we  think,  to  describe,  as  so  many 
authors  do,  all  the  dynamic  affections  of  the  stomach  as  "  neu- 
roses." Some  of  these  troubles  are  purely  muscular.  Some 
of  them  are  exclusively  glandular.  Some  are  auto-intoxica- 
tions. Some  are  psychic,  and  some  are  dependent  upon  dis- 
eases of  the  central  nervous  system  and  of  the  various 
important  organs  of  the  body.  A  very  {^w  are  possibly 
"  neuroses  "  in  the  proper  sense  of  the  word.  All  these  affec- 
tions are  dynamic.  Such  is  their  nature,  and  there  is  nothing 
else  palpable  in  their  manifestations.  We  shall,  consequently, 
devote  a  section  to  the  dynamic  affections  of  the  stomach, 
and  we  believe  that  this  classification  embodies  a  doctrine 
which  is  in  close  conformity  with  the  truth. 

The  displacements  of  the  stomach  are  frequent.  The 
trouble  is  a  purely  physical  one.  The  organ  is  forced  to  do 
its  work  in  an  unfavorable  position.  It  maybe  contended  that 
a  displacement  is  not  a  disease, — /.  e.,  a  morbid  process  in  evo- 
lution,— that  it  is  only  a  condition,  a  result,  an  accident.  But 
it  is  not  a  condition,  which,  like  "  dilatation,"  forms  a  stage 
in  the  orderly  evolution  of  a  disease  of  the  stomach.  It  is 
the  primitive  trouble  of  the  stomach.  It  has  its  own  causa- 
tion and  proper  evolution,  and  can  not  be  understood  apart 
from  them. 

The  book  is  divided  into  six  sections.  The  first  section  is 
introductory. 

The  second  section  treats  of  diagnosis  and  diagnostic 
methods,  the  signs  of  disease  being  arranged  and  classified  in 


2Q  DISEASES  OF  THE  STOMACH. 

the  order  in  which  they  are  obtained  during  the  chnical  ex- 
amination— viz.,  the  chnical  history,  the  physical  signs,  the 
functional  signs,  the  bacteriological  signs,  and  the  anatomical 
signs.  No  chapter  will  be  devoted  to  the  diagnostic  value  of 
the  alterations  of  the  blood,  of  the  qualities  of  the  stools,  and 
of  the  properties  of  the  urine.  The  changes  in  the  blood,  the 
feces,  and  the  urine  will  be  given  in  the  clinical  description  of 
each  disease.  E.xperience  with  the  more  direct  and  exact 
methods  of  investigation  renders  one  very  cautious  in  going 
back  from  the  changes  in  the  blood  and  excretions  to  a  par- 
ticular disease  or  chemical  type.  It  will  not  be  denied  that 
these  deviations  possess  some  confirmatory  diagnostic  value  ; 
but  if  we  attempt  to  go  back  to  the  stomach  from  the  changes 
in  the  blood  and  urine  and  stools,  the  conducting  thread  is 
soon  lost  in  a  network  of  possibilities.  The  chance  of  error 
is  too  great. 

The  third  section  is  devoted  to  general  medication.  The 
principles  of  therapeutics  are  discussed  and  therapeutic 
methods  are  described.  The  first  chapter  treats  of  h\-gienic 
and  physical  remedies.  The  other  ciiapters  are  based  on  the 
information  obtained  by  the  examination  of  the  patient,  the 
kind  of  treatment  corresponding  with  the  variety  of  disease- 
signs — .symptomatic  treatment,  mechanical  treatment,  chemi- 
cal treatment,  physiological  treatment,  and  bacteriological 
treatment. 

These  three  sections  constitute  the  general  or  first  part  of 
the  book.  The  second  or  special  part  of  the  book  is  devoted 
to  particulars,  which  represent  results  and  conclusions.  It 
gives  what  the  physician  at  the  bedside  discovers  with  the  aid 
of  the  methods  of  examination  ;  and  it  applies  the  general 
principles  of  therapeutics  to  the  treatment  of  the  particular 
diseases.  The  fourth  section  (the  beginning  of  the  special 
part  of  the  book)  treats  of  the  dynamic  affections  of  the 
stomach,  while  in  the  fifth  section  are  described  its  anatomical 
diseases.  Departing  from  the  classical  methods,  a  clinical 
description  of  each  disease  is  followed  by  a  discussion  of  its 
diagnostic  signs  in  the  order  given  in  the  second  section, 
which  is  the  natural  method  of  examination. 

The  stomach  is  an  organ  which  rarely  escapes  undisturbed 
when  the  body  or  any  part  thereof  is  seriously  diseased  ;  and 
the  diseased  stomach  may  play  a  part  in  the  causation  of  dis- 
ease of  other  organs.  Be  the  stomach  trouble  a  dynamic 
affection  or  an  anatomical  lesion,  a  knowledge  of  its  reciprocal 
relations  is  e.xceedingly  important.  The  sixth  and  last  section, 
will  describe  the  vicious  circles  of  the  stomach. 


SECTION    II. 
DIAGNOSIS  AND  DIAGNOSTIC  METHODS. 


The  object  of  the  interrogation  and  examination  of  the 
patient  is  the  revelation  of  a  disease.  This  detective  work  is 
known  as  the  diagnosis,  which  forms  the  basis  of  a  well- 
regulated  plan  of  treatment. 

The  diagnosis  includes  the  recognition  of  the  clinical  group 
to  which  the  disease  belongs,  and  the  discovery  of  its  nature, 
stage,  associations,  and  complications. 

The  diagnosis  of  a  disease  of  the  stomach  includes  more 
than  a  knowledge  of  the  pathological  chemistry  of  digestion. 
The  unhealthy  variations  of  the  gastric  juice,  the  perversion 
of  the  motor  function,  the  little  variations  in  the  quantity  of 
the  hydrochloric  acid  secreted  or  left  free,  occupy  too  much 
and  too  exclusively  the  minds  of  some  practitioners.  Our 
knowledge  of  these  troubles  rests  on  as  sure  and  broad  a 
foundation  as  does  our  knowledge  of  any  other  class  of 
internal  diseases,  and  includes  all  the  truth  revealed  by  all  the 
methods  of  investigation  that  give  a  new  or  an  additional 
light.  The  theory  should  be  constructed  out  of  all  the  signs 
and  symptoms  and  not  be  made  dependent  on  the  functional 
signs  alone,  or  chiefly.  Under  the  glare  of  novelty  the  older 
methods  have  become  too  much  neglected,  and  what  is  new 
is  given  too  great  value  and  employed  too  exclusively  and 
indiscriminately. 

Each  new  method  of  investigation  destroys  and  creates, 
and  modifies  profoundly  the  theory  of  particular  branches  of 
internal  medicine.  This  was  the  case  with  the  diseases  of  the 
chest  after  the  adoption  of  the  method  of  L^nnec.  Such  was 
also  the  effect  of  the  introduction  of  the  ophthalmoscope,  and 
the  laryngoscope,  and  the  cystoscope  in  a  less  degree.  Each 
method  that  reveals  the  interior  of  one  of  the  cavities  creates 
a  revolution. 

Only  a  few  years  ago  the  subjective  sensations  gave  the 
greatest  part  of  the  information  utilized  in  diagnosis  con- 
cerning the  diseases  of  the   stomach.     The  clinical  examina- 

21 


2  2  DISEASES  OF  THE  STOMACH. 

tion  was  nearly  resultless,  and  was  confined  to  the  detection 
of  gross  abnormalities  of  size,  form,  location,  density,  and 
sensitiveness.  More  recent  methods  reveal  the  functional 
power,  while  the  older  methods  have  been  made  more  exact 
and  technical,  and  the  precision  and  definiteness  of  all  the 
diagnostic  signs  have  been  correspondingly  increased. 

The  diagnostic  methods  are  both  special  and  general. 
Some  of  the  procedures  are  such  as  are  employed  in  the 
diagnosis  of  all  internal  diseases,  while  others  are  used  only 
in  the  diagnosis  of  the  diseases  of  the  stomach. 

The  direct  investigation  of  the  digestive  functions  is  a 
modern  procedure.  It  has  yielded  a  new  set  of  signs  of  the 
very  greatest  value  at  the  bedside.  The  stomach-tube  has 
also  enriched  clinical  medicine,  by  adding  to  it  the  bacterio- 
logical and  anatomical  signs  of  the  diseases  of  the  stomach. 

To  the  methods  peculiar  to  the  diagnosis  of  the  diseases  of 
the  stomach  should  be  added  the  more  common  procedures 
of  physical  diagnosis  and  their  modifications  in  the  examina- 
tion of  the  digestive  organs.  The  modified  technic  and 
special  devices  will  receive  a  careful  and  exact  description  in 
order  that  the  fullest  information  of  diagnostic  value  may  be 
rapidly  obtained. 

The  revealing  signs  and  symptoms  are  subjective  and  objec- 
tive, or  such  as  are  perceived  and  related  by  the  patient  and 
are  detected  by  the  physician.  The  one  constitutes  the  clini- 
cal history;  the  other  the  clinical  examination. 

The  clinical  history  and  examination  give  the  data  from 
which,  by  induction,  the  diagnosis  is  drawn.  The  logical  pro- 
cess is  an  inductive  one,  but  the  analysis  is  supplemented 
by  synthesis,  or  the  orderly  arrangement  of  the  salient  and 
valuable  points  of  the  clinical  history,  and  the  physical,  the 
functional,  the  bacteriological,  and  the  anatomical  signs.  After 
the  clinical  history  and  the  examination  are  completed,  the 
symptoms  and  signs  are  arranged  in  the  order  of  their  evolu- 
tion and  in  their  proper  causal  relations.  The  symptom-group 
is  next  compared  with  known  clinical  types  and  the  disease 
classified  according  to  its  clinical  expression.  Following  the 
thread  found  in  the  modification  of  function  and  the  evolution 
of  unhealthy  variations,  we  arrive  in  a  natural  way  at  the 
clinical,  functional,  and  anatomical  diagnosis.  The  more 
exact  and  complete  the  data,  the  surer  is  the  conclusion 
reached  in  this  way.  The  result  is  dependent  on  the  skill  of 
the  physician,  the  truthfulness  and  intelligence  of  the  patient, 
and  the  exactness  and  efficiency  of  the  methods. 

The  constructed    symptom-group    rarely  corresponds    in 


DIAGNOSIS  AND    DIAGNOSTIC  METHODS.  23 

every  detail  with  a  special  clinical  type,  but  may  be  the  ex- 
pression of  more  than  one  disease.  By  exclusion  the  diag- 
nosis is  made  exact,  and  the  precision  essential  to  purposive 
treatment  is  attained.  This  process  is  commonly  known  as 
differential  diagnosis,  and  is  reached  by  deduction,  comparison, 
and  exclusion.  The  exclusion  of  the  disease  suggested  by 
the  symptom-group  may  be  dependent  on  the  absence  of  a 
cardinal  symptom  or  sign.  The  result,  though  based  on  a 
negation,  is  none  the  less  sure. 

After  the  symptom-group  is  classified  and  given  a  particu- 
lar name,  a  comparison  is  then  made  with  the  typical  clinical 
form  of  the  malady,  and  an  explanation  is  sought  for  the 
variations  of  type.  The  individual  and  medical  constitution 
are  thus  brought  prominently  into  view,  and  a  complication 
or  an  associated  disease  may  be  revealed.  If  the  situation  is 
thus  found  to  be  complex,  a  further  problem  is  the  discovery 
of  the  relations  of  the  parts,  or  the  associated  morbid  enti- 
ties. As  a  rule,  one  disease  is  the  primary  and  predominant 
one.  But  the  presence  of  a  complication  which  may  be  ex- 
plained as  a  result  is  not  conclusive  of  such  a  mode  of  origin, 
and  may  lead  to  a  false  conception  of  the  supposed  causative 
disease.  Accidental  independent  associations  are  not  rare. 
That  a  disease  may  be  explained  as  a  complication  does  not 
exclude  the  possibility  of  its  independent  existence  and  de- 
velopment. Two  possible  explanations  of  a  symptom-group 
may  be  equally  plausible,  and  precision  in  the  diagnosis  may 
be  impossible.  In  such  cases  a  supposition  should  not  be 
mistaken  for  and  defended  as  the  truth. 

A  disease  may  have  no  characteristic  sign  or  symptom- 
group.  The  expression  maybe  irregular,  indefinite,  formless. 
The  deductive  method  may  then  be  of  use. 

No  mistake  is  more  common  than  to  leave  out  of  consider- 
ation the  stage  of  the  disease.  The  symptom-group  of  an 
advanced  disease  is  markedly  modified  by  the  constitutional 
state.  The  organism  suppresses  or  modifies  the  expression 
of  the  disease,  and  the  former  salient  features  are  lost.  This 
is  particularly  true  of  the  final  stages  of  a  disease,  when  the 
diagnosis  is  more  clearly  revealed  by  the  clinical  history  than 
by  the  present  state.  The  death  agony  so  changes  the  ex- 
pression as  to  suggest  often  the  possibility  of  an  erroneous 
diagnosis.  The  mode  of  death  is  the  same  in  many  widely 
different  diseases.  The  nature  of  a  disease  is  revealed  by  its 
life  history. 

Diagnosis  is  a  logical  method,  proceeding  by  analysis,  syn- 
thesis, comparison.     The   mode  of  reasoning    employed  has 


24  DISEASES  OE  THE  STOMACH. 

been  described.  Diagnosis  is  also  a  methodical  procedure. 
In  taking  the  clinical  history  and  making  the  clinical  exami- 
nation, in  order  to  avoid  error  and  loss  of  time  we  should 
adhere  strictly  to  a  general  plan.  The  clinical  examination 
begins  with  the  medical  constitution,  the  strength,  and  the 
state  of  nutrition.  Then  look  over  the  skin  and  visible  mu- 
cous membranes  and  search  for  enlarged  glands.  This  is  to  be 
done  in  every  case.  The  next  step  is  the  examination  of  the 
organ — the  stomach,  for  example — indicated  by  the  clinical 
history  as  the  seat  of  the  disease.  This  being  completed,  we 
go  on  to  the  examination  of  the  other  organs,  neglecting  in 
no  case  to  examine  the  liver,  the  nervous  system,  the  heart 
and  the  blood-vessels,  the  lungs,  and  the  kidneys.  An  exami- 
nation of  the  blood  and  the  urine,  and  of  the  stools,  should 
never  be  neglected  ;  and  the  female  genital  organs,  if  not 
functionating  properly,  should  also  be  examined.  The  pres- 
ence of  a  causative  or  associated  disease  may  make  the  treat- 
ment of  a  disease  of  the  stomach  a  failure. 

A  complete  diagnosis  of  a  disease  of  the  stomach  is  not  a 
simple  or  an  easy  matter.  In  the  clinical  history  are  found 
such  symptoms  as  point  to  this  organ  as  the  location  of  the 
trouble.  The  process  of  reasoning  by  which  the  nature  of 
the  disease  and  its  clinical  form  are  detected  has  just  been 
outlined.  But  a  complete  practical  diagnosis  of  a  trouble  of 
the  stomach  includes  much  more.  In  the  first  place,  the 
clinical  form  should  be  recognized,  when  our  attention  is 
limited  to  the  predominant  characteristics  revealed  in  the 
manner  of  the  manifestations.  The  grand  clinical  character  is 
dynamic,  and  is  either  hypersthenic  or  asthenic.  These  are 
the  two  clinical  forms,  and  are  the  clinical  expression  of  ex- 
cessive or  of  insufficient  activity.  The  diagnosis  of  the  clinical 
form  characterizes  in  a  general  manner  the  treatment,  be  it 
sedative,  indifferent,  or  excitant. 

The  physical  examination  yields  the  physical  signs,  or 
those  obtained  by  inspection,  palpation,  percussion,  ausculta- 
tion, inflation,  and  electric  illumination. 

The  functional  signs  maJ<e  clear  the  actual  work  done  by 
the  stomach,  and  form  the  basis  of  physiological  treatment. 

The  pathological  stomach  may  become  the  breeding-place 
of  micro-organisms  which  destroy  the  food,  rob  the  body  of 
its  nutriment,  irritate  the  stomach,  and  poison  the  system. 
The  bacteriological  signs  possess  an  intense  practical  interest. 

Special  therapeutic  indications  are  given  by  the  anatomical 
lesions,  the  determination  of  the  nature  of  which  is  often 
facilitated  by  the  anatomical  signs. 


THE  CLINICAL   HISTORY.  2$ 

These  signs  and  the  clinical  history  combined  reveal  the 
nature  and  stage  and  probable  evolution  of  the  disease,  and 
suggest  the  treatment. 

We  shall  describe  them  in  the  following  order,  which  is  the 
one  most  natural  at  the  bedside  : 

1.  The  Clinical  History. 

2.  The  Physical  Signs. 

3.  The  Functional  Signs. 

4.  The  Bacteriological  Signs. 

5.  The  Anatomical  Signs. 


CHAPTER  1.      . 
THE  CLINICAL  HISTORY. 

The  revelations  of  the  modern  methods  of  examining  the 
stomach  have  so  deeply  engaged  the  attention  of  the  medical 
world  that  the  diagnostic  value  of  the  clinical  history  has 
been  almost  forgotten.  The  improved  technic  of  physical 
diagnosis,  the  more  exact  and  the  more  frequent  clinical  study 
of  the  functions  of  the  stomach,  the  more  intimate  knowledge 
of  the  conditions  and  the  effects  of  fermentation  and  putre- 
faction, the  search  for  anatomical  signs  in  the  contents  of  the 
stomach,  and  the  recent  advances  of  pathology,  have  dimin- 
ished the  obscurity  which  has  so  long  concealed  the  nature, 
the  genesis,  and  the  evolution  of  stomach  diseases.  But 
notwithstanding  the  increase  of  knowledge,  notwithstanding 
the  great  precision  of  modern  diagnostic  methods,  the  clin- 
ical history  still  maintains  all  its  old  utility.  The  diagnostic 
value  of  the  subjective  symptoms  has  only  been  enhanced  by 
our  more  exact  knowledge  of  their  genesis  and  their  evolu- 
tion. 

Unfortunately,  many  practitioners  do  not  accept  this  view, 
but  deem  the  time  wasted  which  is  spent  in  obtaining  the 
subjective  history.  Many  of  the  constitutional  symptoms,  it 
may  be  readily  admitted,  are  common  to  all  forms  of  gastric 
trouble,  and  are  of  little  value  in  clinical  investigation. 
Many  symptoms,  also,  are  in  no  fixed  relation  to  the  cause, 
or  to  the  chemical  pathology,  or  to  the  anatomical  lesion  ; 
and  the  complaints  of  the  patient  may  be  so  general  as 
to    be    meaningless.     The   numerous   and    different    diseases 


26  DISEASES  OF  THE  STOMACH. 

of  tlie  stomach  may  have  a  similar  group  of  subjective  symp- 
toms. No  one  symptom  is  pathognomonic,  and  even  the 
collections  of  symptoms,  although  more  characteristic  and 
more  suggestive,  are  hardly  less  likely  to  lead  to  an  erroneous 
diagnosis.  Taken  singly  or  combined,  the  physician  may 
only  be  able  to  conftrm  the  patient's  statement  that  he  is 
suffering  from  a  "  bad  stomach  "  ;  and  this  does  not  lead  very 
far  toward  a  rational  diagnosis  or  a  purposive  treatment. 

It  is  quite  true  that  the  bundle  of  sensations  or  perceptions 
is  often  valueless  in  the  naked  abstract ;  and,  therefore,  a 
thorough  search  must  be  made  for  the  individualizing  char- 
acteristics and  the  definitive  features. 

To  search  out  and  keep  before  the  mind  the  useful  subjec- 
tive symptoms  is  essential  to  the  proper  utilization  of  the 
clinical  history.  The  chief  importance  attaches  not  to  the 
gross  symptom,  but  to  its  characteristics.  The  diseases  of  the 
stomach  are  not  silent,  and  they  commonly  speak  distinctly. 
Rarely,  it  may  be  otherwise.  A  disease  of  the  kidneys,  a  com- 
pensated heart  lesion,  a  disease  of  the  liver,  may  long  exist 
without  creating  a  suspicion.  This  may  also  happen  with  a 
disease  of  the  stomach,  and  the  first  revealing  sign  may  be 
given  by  the  disturbance  of  the  function  of  some  other  organ, 
or  the  patient  may  be  so  accustomed  to  a  "  bad  stomach  "  as 
to  consider  its  existence  meaningless,  and  may  consult  the 
physician  for  some  other  trouble — insomnia,  palpitation,  loss 
of  strength,  emaciation,  cerebral  fatigue.  But  in  the  large 
majority  of  cases  the  voice  is  more  distinct,  and  is  heard 
where  it  is  produced.  It  is  quite  proper  to  speak  of  an  ulcer 
history,  a  gastritis  history,  a  cancer  history,  a  myasthenia 
history,  a  history  of  neurasthenia  gastrica,  or  a  history  of 
any  of  the  clinically  well-defined  diseases  of  the  stomach  ; 
but  to  be  of  value,  the  history  must  be  compiled  by  the 
physician  out  of  the  material  furnished  by  his  purposive  ques- 
tioning of  the  patient. 

The  interrogation  of  the  patient  demands  tact  and  experi- 
ence, and  a  knowledge  of  human  nature  and  of  the  "  dyspep- 
tic." The  "  dyspeptic  "  is  a  poor  student  of  himself,  but  a 
lover  of  criticism.  Unguided,  his  story  consists  chiefly  of  the 
numerous  drugs  he  has  taken,  and  the  many  physicians  whom 
he  has  consulted  without  benefit.  Acrimonious,  full  of 
opinions,  he  remembers  vagueU'  and  relates  unwillingly  the 
facts  concerning  his  digestive  trouble,  except  in  the  light  of  a 
preconceived  opinion.  The  physician,  who  is  supposed  to  be 
familiar  with  the  clinical  pictures  of  the  different  diseases  of 
the  stomach,  should,  by  well-chosen  questions,  concentrate  the 


THE  CLINICAL   HISTORY.  2/ 

inquiry  and  the  attention  on  the  distinctive  and  characteristic 
symptoms  and  the  symptom-groups.  The  most  detailed  de- 
scription by  the  patient  is  much  less  valuable  than  a  clinical 
history  made  out  on  broad  schematic  lines.  Seize  at  once  the 
most  important  points  in  the  patient's  story,  and  follow  with 
questions  so  formed  as  to  define  more  clearly  the  relations  of 
the  symptoms. 

It  must  not  be  supposed  that  the  clinical  history  suffices, 
alone,  to  make  a  diagnosis.  The  atypical  and  the  secondary 
diseases  of  the  stomach,  without  the  signs  revealed  by  an 
examination,  are  likely  to  be  overlooked.  Even  when  the 
clinical  history  of  the  stomach  disease  is  most  typical,  the 
possibility  of  associated  diseases  must  be  remembered,  and 
there  may  be  complications. 

The  clinical  history  opens  up  the  way  for  further  and  more 
exact  investigation.  The  interrogation  is  an  introduction  and 
a  guide  to  the  clinical  examination.  The  interrogation,  how- 
ever, should  not  be  made  the  basis  of  a  diagnosis  ;  for  such 
a  course  may  lead  to  serious  errors.  The  following  case 
illustrates  and  emphasizes  this  principle :  A  patient,  aged 
thirty-eight,  nervous  temperament,  was  severely  shocked  by 
the  sudden  and  accidental  death  of  his  wife.  The  appetite 
began  to  fail,  the  stomach,  after  meals,  felt  uncomfortably  full, 
and  the  period  of  digestion  was  accompanied  by  restlessness, 
nervousness,  but  by  no  pain.  Liquids  produced  more  distress 
than  solid  food,  and  a  full  meal  increased  his  discomfort  and 
his  mental  despondency.  The  patient  had  lost  a  few  pounds 
in  weight  during  the  four  months  since  the  beginning  of  the 
attack,  but  the  diet  was  less  than  supporting.  Myasthenia 
gastrica  was  suspected,  and  the  trouble  was  supposed  to  be 
dynamic.  The  examination  revealed  the  functional  signs  of 
carcinoma,  and  an  elongated,  ridge-like,  hard  tumor  could  be 
felt  just  below  and  to  the  left  of  the  ensiform  cartilage,  moving 
with  respiration,  but  with  difficulty  fixable  on  expiration. 
The  subsequent  history  proved  the  diagnosis  of  carcinoma 
ventriculi  to  be  correct. 

The  story,  as  told  by  the  patient,  is  a  bundle  of  uninter- 
preted or  mistakenly  interpreted  sensations.  The  nature  of 
the  disease  may  often  be  revealed  by  the  manner  in  which 
the  history  is  gathered  up  and  related.  But,  as  a  rule,  neither 
the  nature  nor  the  location  of  the  disease  is  revealed  in  this 
way.  The  trouble  may  be  in  the  stomach,  the  colon,  or 
the  gall-bladder,  or  in  some  other  abdominal  organ.  The 
subjective  symptoms  of  a  benign  or  a  malignant  disease  are 
frequently  alike.    The  clinical  history  may,  but  does  not  often. 


28  DISEASES  OF  THE  STOMACH. 

suffice;  }-et  it  may  reveal  the  location  and  the  ori<^in,  and  even 
the  nature,  of  the  trouble.  To  amass  information  on  these 
three  points  is  one  of  the  objects  in  questioning  the  patient. 

The  first  problem  is  the  location  of  the  disease.  This,  at 
first  glance,  may  seem  very  easy  of  solution  ;  but  here  mis- 
takes are  very  often  made.  It  has  been  often  urged  that  the 
specialist  is  too  prone  to  locate  disease  in  the  particular 
organ  or  organs  which  he  exclusively  treats.  It  has  long 
been  the  custom  to  attribute  all  the  gastro-intestinal  and  the 
nervous  symptoms  of  enteroptosis  to  a  displacement  or  a 
version  of  the  uterus.  The  eye  and  the  nose  have  been  no 
less  pretentiously  forced  upon  our  attention  ;  and  the  stomach 
and  the  intestines,  on  account  of  their  wide  s\-mpathies  and 
relations,  are  no  less  apt  to  monopolize  our  study. 

It  is  a  mistake  to  direct  the  questioning  solely  to  the  diges- 
tive function.  There  are  diseases  of  the  stomach  that  present 
no  local  subjective  sign.  These  diseases  may  express  them- 
selves at  a  distance,  and  do  their  marauding  far  away  from 
their  home — in  the  head,  or  the  heart,  or  the  lungs,  or  the 
kidneys,  or  the  liver,  or  the  sympathetic  or  central  nervous 
system.  There  are  also  diseases  of  other  organs,  the  only 
subjective  manifestation  of  which  is  a  disorder  of  the  stomach. 
The  two  following  cases  illustrate  what  is  meant :  A  patient 
with  a  very  violent  headache  came  for  consultation ;  there 
was  no  syphilitic  history,  and  no  malaria,  no  neurasthenia, 
no  disease  of  the  kidneys,  and  no  uricemia  were  found.  The 
headache  was  at  times  periodical,  at  times  remittent,  at  times 
accompanied  at  night  by  insomnia  and  irritable  temper,  at 
times  most  violent  during  the  day  ;  there  was  no  fixed  rela- 
tion to  the  period  of  gastric  digestion,  or  to  constipation,  or 
to  excesses  ;  it  was  without  definitive  features,  and  the  patient 
was  not  conscious  of  any  abdominal  symptoms.  The  exami- 
nation revealed  a  prolapsed  myasthenic  stomach,  with  stag- 
nation and  fermentation.  Again,  a  young  married  woman 
came  complaining  of  very  troublesome  vomiting.  There 
were  no  other  subjective  or  objective  gastric  symptoms.  The 
uterus  was  normal  and  non-pregnant.  Upon  further  ques- 
tioning it  was  learned  that  the  vomiting  was  always  preceded 
by  coughing,  and  an  examination  revealed  an  incipient  pul- 
monary tuberculosis,  the  primary  disease.  Gastric  trouble  is 
so  commonly  a  companion  of  the  diseases  of  other  organs 
that  the  physician,  cognizant  only  of  the  abdominal  symptoms, 
is  likely  to  form  a  false  conclusion.  Study  the  wliole  man, 
and  learn  to  know  him  in  every  part. 

The   general    history  should  always  precede  that    of  the 


THE  CLIXICAL    HISTORY.  29 

abdomen.  The  local  phenomena  being  next  studied,  and  a 
provisional  diagnosis  formed,  the  known  effect  of  the  disease  of 
the  stomach  on  the  organism  should  be  looked  for  as  a  con- 
firmation of  the  hypothesis.  The  general  history  in  its  grand 
lines,  the  local  phenomena  in  every  detail  and  relation,  the 
minute  search  for  the  usual  effects  of  the  suspected  disease, 
is  the  natural  method  of  conducting  the  preliminary  exami- 
nation. The  following  case  illustrates  the  simplicity  of  this 
natural  method  :  A  young  clerk  had  always  enjoyed  excel- 
lent health  before  an  attack  of  typhoid  fever,  three  years  ago. 
Convalescence  was  slow,  but  his  appetite  and  occupation 
forced  him  to  eat  ravenously  and  rapidly.  For  the  two 
following  years  he  was  conscious  of  having  a  bad  stomach, 
intolerant  of  large  quantities  of  fluid  and  of  large  meals. 
Moderation  would  cause  the  headache,  insomnia,  mental  de- 
pression, and  gastric  uneasiness  and  heaviness  to  disappear. 
Six  months  ago,  the  morning  after  a  heavy,  indigestible 
dinner  and  several  drinks,  he  had  a  severe  attack  of  headache, 
nausea,  sour  and  foul  vomiting,  which  continued  for  several 
days.  Since  that  time  he  has  been  worse,  and  vomits  large 
quantities  of  fluid — sour,  brown,  sometimes  foul,  containing 
food,  etc.,  eaten  the  day  before.  During  the  past  six  months 
he  has  rapidly  emaciated  ;  the  skin  is  dry  and  rough,  the 
urine  is  scant,  feet  and  hands  are  cold,  there  are  cramps  in 
the  calves  of  the  legs,  "  the  hands  and  feet  often  go  to  sleep," 
and  the  nodosities  of  Bouchard  are  very  plain.  These  are 
retention  symptoms.  The  stomach  is  not  empty  in  the  morn- 
ing, the  vomit  "  three  layer,"  and  contains  sarcina^.  Test- 
breakfast,  after  frequent  lavage,  gives  free  HCl.  Diagnosis — 
myasthenia  gastrica,  with  retention. 

The  disease  being  located  and  classified,  it  is  natural  that 
we  should  next  search  for  its  cause.  This  may  be  found  in 
the  alimentation,  the  profession,  the  home  life,  the  family 
history,  or  in  a  past  disease.  It  is  specially  valuable  to  know 
the  beginnings  of  the  trouble ;  for  at  this  early  period  we  are 
nearest  to  the  cause,  and  the  disease  is  yet  central,  undiffer- 
entiated, and  uncomplicated.  The  surroundings  of  the 
patient  at  this  time,  his  habits  and  diet,  should  be  carefully 
looked  into.  The  patient,  if  intelligent,  may  know  the  cause, 
and  his  opinion  should  be  patiently  heard. 

Such  is  the  value  of  the  clinical  history.  Such  is  the  proper 
and  natural  method  of  obtaining  it  and  of  using  it  in  diag- 
nosis. The  subjective  symptoms  are  the  manifestations  of 
the  disease,  and  often  reveal  its  nature  when  their  evolution 


30  DISEASES  OF  THE  STOMACH. 

and  diagnostic  features  are  discovered.     The  clinical  history 
includes  : 

1.  The  general  history  of  the  patient  before  the  beginning 
of  the  present  trouble.  In  his  past  we  may  see  the  shadows 
of  coming  events.  Diseases  of  other  organs  are  selective  in 
their  influence  on  the  stomach,  and  may  give  a  clue  to  the 
genesis  and  the  nature  of  the  present  trouble. 

2.  The  history  of  the  present  trouble. 

3.  The  present  condition  of  the  patient,  which  is  most  sat- 
isfactorily revealed,  under  the  guidance  of  the  physician,  by 
his  own  relation  of  the  history  of  a  single  day. 

I.  The  Previous  History. — A  disease  of  the  stomach,  both 
in  its  nature  and  its  evolution,  is  conditioned,  among  other 
things,  by  the  cause  and  the  medical  constitution.  It  has 
been  contended  that  the  pathological  anatomy  bears  no  rela- 
tion to  the  nature  of  the  disease,  and  that  the  symptoms  are 
not  an  expression  of  the  lesion.  In  neither  the  primary  nor 
the  secondary  diseases  of  the  stomach  is  this  contention  true. 
In  the  sixth  section — on  the  vicious  circles  of  the  stomach — it 
will  be  made  clear  in  how  intimate  a  relation  a  secondary  dis- 
ease of  the  stomach  stands  to  the  disease  which  has  caused 
it.  It  is  on  the  reality  of  this  relation  that  the  diagnostic 
value  of  the  previous  history  depends,  and,  consequently, 
much  of  the  information  amassed  in  that  section  will  aid  in 
the  detection  of  the  nature  of  the  particular  disease  of  the 
stomach. 

The  older  clinicians  laid  great  stress  on  the  medical  consti- 
tution, and  it  is  to  be  regretted  that  the  diagnostic,  prognos- 
tic, and  therapeutic  rules  dependent  thereon  have  been  allowed 
to  drop  into  oblivion.  The  medical  constitution,  be  it  inher- 
ited or  acquired,  is  the  soil  in  which  the  disease  is  to  grow, 
and  consequently  conditions  both  its  evolution  and  the  char- 
acter of  its  results.  The  physician  at  the  hospital  overlooks 
it ;  but  the  physician  who  knows  the  individual  and  the 
family  detects  the  unique  and  persistent  force  revealing  itself 
successively  by  troubles  very  various,  but  one  in  causation 
and  treatment — this  concealed  unitv'^  of  which  the  arthritic 
and  neuropathic  groups  of  diseases  are  the  simplest  examples. 
What  is  true  of  a  diathesis  is  also  true  of  a  temperament, 
and  of  the  new  and  special  adaptations  necessitated  by  dis- 
ease and  environment.  One  who  studies  the  present  condi- 
tion ma\'  detect  the  functional  trouble,  the  anatomical  lesion, 
and  its  seat ;  he  will  see  nothing  of  this  individual  peculiarity 
revealed    in   the  evolution  and   the   mode  of  expression  and 


THE  CLINICAL   HISTORY.  3  I 

formation  of  family  disease-groups,  and  demanding  long- 
continued  patience,  courage,  and  a  treatment  of  the  morbid 
individual  life.  The  study  of  the  previous  history  reveals  the 
individual  medical  constitution,  and  the  probable  nature  of 
the  secondary  and  diathesic  diseases  of  the  stomach.  We 
come  now  to  the  history  of  the  present  trouble — its  prelude, 
the  manner  and  date  of  its  beginning,  and  its  evolution. 

2.  The  History  of  the  Present  Trouble. — The  prelude  to 
the  development  of  a  disease  of  the  stomach  contains  the 
exciting  and  often  the  remote  cause.  This  period  of  the 
medical  history  should  be  very  closely  studied,  with  a  view  to 
first  locating  the  cause  in  the  organism,  or  in  alimentation 
and  the  material  introduced  into  the  stomach.  At  this  time 
the  cause  and  the  constitution  together  will  suggest  more 
definitely  the  nature  of  the  trouble  than  at  a  period  more 
remote  from  the  beginning.  These  causes,  be  they  mechani- 
cal or  vital,  act  through  the  five  functional  factors — the 
nervous  system,  the  circulation  and  quality  of  the  blood, 
secretion,  muscular  action,  and  absorption. 

The  age  at  which  the  trouble  began  may  suggest  the  prob- 
ability or  the  absence  of  certain  diseases.  Cancer  is  very 
rare  before  the  middle  third  of  life.  Myasthenia  is  more 
and  more  frequent  with  advancing  years.  Adenohyper- 
sthenia  gastrica  diminishes  from  manhood  to  old  age.  Ulcer 
is  somewhat  rare  before  twenty.  The  hypersthenic  motor 
and  sensory  affections  accompany  puberty  and  youth.  Ano- 
rexia nervosa,  nervous  vomiting,  and  gastralgia  are  most 
frequent  in  young  girls  and  middle-aged  women. 

The  symptoms  of  the  beginning  often  reveal  at  once  the 
nature  of  the  affection.  The  acute  inflammations,  and  often 
the  dynamic  affections,  begin  suddenly,  with  characteristic 
symptoms.  Chronic  diseases,  when  so  from  the  start,  begin 
slowly  and  quietly.  Ulcer  may  announce  itself  by  a  hemor- 
rhage, or  by  an  unheralded  perforation,  but  more  frequently 
by  digestive  irritation  in  strict  relation  with  the  physical  action 
of  the  food.  Myasthenia  is  usually  insidious  in  its  beginning, 
but  may  progress  with  a  bound  after  an  excessive  meal. 
Cancer  most  frequently  begins  in  the  midst  of  seemingly  good 
health,  with  symptoms  due  to,  and  increasing  with,  the  motor 
insufficiency,  the  facility  with  which  the  food  taken  ferments 
and  taxes  the  peristaltic  and  evacuating  power.  The  displace- 
ments begin  with  traction  symptoms  ;  a  completed  displace- 
ment may  long  remain  symptomless,  but  it  becomes  a  con- 
scious disease  when  abdominal  tension  diminishes  or  myas- 
thenia  gastrica,   particularly   with   fermentation,   supervenes. 


32  DISEASES  OF  THE  STOMACH. 

When  all  tlie  physiological  factors  of  digestion  are  more  or 
less  implicated,  the  symptom-group  of  the  beginning  is  com- 
monly more  characteristic  than  that  of  a  later  period.  The 
disease  of  the  stomach  may  be  displayed  more  characteris- 
tically, if  not  more  intensely,  in  the  phenomena  which  attend 
its  origin. 

The  evolution  of  the  subjective  symptoms  may  be  inter- 
mittent, remittent,  or  progressive.  The  course  of  many  dis- 
eases of  the  stomach  is  marked  by  periodicity  and  by  parox- 
ysms. These  qualities  may  be  inherent  in  the  nature  of  the 
trouble,  the  attacks  seeming  to  recur  spontaneously  or  as  the 
expression  of  accumulated  incompetence,  each  day  the  organ 
becoming  more  exhausted  or  irritated  under  the  strain  of  ex- 
cessive work.  In  the  interval,  digestion  is  unconscious,  and 
an  ordinary  mixed  diet  is  well  borne.  Most  of  the  dynamic 
affections  may  be  periodical  or  paroxysmal,  the  attacks  often 
being  excited  by  errors  of  diet,  physical  excesses,  or  mental 
and  moral  strain. 

In  other  cases,  the  course  is  characterized  by  remissions. 
The  interval  is  a  period  of  improvement,  but  not  of  health. 
The  disease  continues,  but  is  not  uniform  in  the  intensity  of 
its  expression.  Without  these  exacerbations,  the  patient 
would  not  consult  a  physician.  During  the  period  of 
remission,  the  capability  of  the  diseased  stomach  is  better 
adapted  to  the  work  demanded  of  it.  During  the  exacerba- 
tion, this  compensation  is  disturbed  by  mental,  moral,  or 
physical  influences,  or  by  bad  hygiene,  improper  diet,  and 
injurious  remedies.  This  is  the  course  most  characteristic 
of  the  anatoinical  diseases  of  the  stomach.  Both  the  re- 
missions and  the  exacerbations  may  be  due  to  "  little  acci- 
dents." Another  organ  may  become  insufficient,  and  include 
the  stomach  in  the  vicious  circle.  The  offending  matter  may 
be  vomited,  or  may  be  evacuated  into  the  intestine.  After  a 
hemorrhage,  the  subjective  symptoms  of  a  gastric  ulcer  may 
subside. 

But,  be  the  course  intermittent,  remittent,  or  continuous, 
progression  in  spite  of  proper  treatment  is  a  suggestive  evo- 
lution sign.  The  obstinacy  is  due  to  the  character  of  the 
lesion  itself  This  malign  tendency  is  most  constant  in  car- 
cinoma, the  gross  subjective  symptoms  of  which  may  often  be 
controlled  or  mitigated  by  judicious  treatment,  but  each  day 
the  disease  burns  more  and  more  of  the  albumin  of  the  body, 
and  brings  the  patient  nearer  to  the  grave. 

The  evolution  of  a  disease  of  the  stomach  may  be  slow  or 
rapid.     The  clinical   period  of  cancer  does   not  last  longer 


THE  CLINICAL   HISTORY.  33 

than  twelve  to  eighteen  months.  The  dynamic  affections  may- 
continue  for  years,  or  may  suddenly  begin,  run  a  rapid  course, 
and  just  as  suddenly  end.  The  constitution,  the  moral  atmos- 
phere, and  the  mode  of  life  have  much  to  do  with  the  per- 
sistence of  these  troubles.  Acute  gastritis  and  ulcer  may 
soon  heal,  but  the  displacements  and  anatomical  diseases  of 
the  stomach  have  a  tendency  to  persist.  Expectant  treatment 
has  no  ally  in  an  inherent  tendency  to  get  well,  and  the  dis- 
eases of  the  stomach  recur  more  frequently  than  those  of  any 
other  organ. 

Some  diseases  are  also  accompanied  by  diminished  power 
of  the  organism  to  repair  its  losses,  or  to  recuperate  after 
triflmg  accidents.  In  ulcer,  the  effects  of  a  hemorrhage  may 
rapidly  disappear,  because  the  disease  is  a  local  one,  and  the 
motor  power  of  the  stomach  is  good.  The  emaciation  is  due 
to  voluntary  starvation,  unless  the  food  be  lost  by  vomiting 
or  by  retention  from  pyloric  swelling  or  stenosis.  After  a 
hemorrhage  in  cancer,  the  patient  sinks  more  rapidly  under 
the  auto-intoxication  and  the  inanition.  This  diminished  re- 
cuperative power  also  characterizes  the  uncompensated  dis- 
eases of  the  stomach. 

The  evolution  of  a  dynamic  affection  of  the  stomach  may 
end,  eventually,  in  a  destruction  of  a  large  part  of  the  noble 
elements  of  the  organ.  The  different  stages  are  links  of  one 
chain.  Adenohypersthenia  gastrica  may  terminate  in  gas- 
tritis and  atrophy,  and  the  early  hypersthenia  may  develop 
into  the  most  complete  asthenia.  The  symptom-group  is 
correspondingly  changed  by  the  substitution  of  the  signs  of 
depression  for  those  of  irritation.  Pain  is  no  longer  com- 
plained of,  and  vomiting  may  occur  only  as  a  result  of  over- 
distention,  or  as  a  pressure  symptom  reflected  from  an  adja- 
cent abdominal  organ.  In  cancer,  for  example,  vomiting  is 
rare  in  the  beginning,  may  become  uncontrollable,  and  then 
disappear  entirely  as  the  disease  progresses.  Retention  marks 
a  turning-point  in  the  history  of  a  disease  of  the  stomach. 
The  delay  in  evacuation  becomes  greater  and  greater,  until 
finally  the  stomach  never  empties  itself  completeh' ;  this 
condition  robs  the  system  of  its  nutriment,  and  forms  a 
persistent  culture-soil  for  micro-organisms,  since  the  stomach 
always  has  something  in  it.  The  clinical  picture  becomes 
modified  by  the  little  accidents  without  the  natural  evolution 
being  interrupted.  The  morbid  unity  is  preserved  beneath 
the  play  of  expression.  These  changes  of  type  develop  in  so 
orderly  a  manner  as  to  be  of  value  in  determining  the  nature 
of  the  anatomical  disease  following  the  dynamic  affection. 
3 


34  DISEASES  OF  THE  STOMACH. 

The  effects  of  treatment  on  the  evolution  of  the  disease 
may  reveal  its  nature.  In  cancer,  the  treatment,  however 
purposive,  only  relieves  the  gross  symptoms  of  stagnation  or 
retention.  The  effect  of  alkalies  is  of  differential  value.  If 
large  doses  of  the  alkaline  waters  or  drugs  give  relief,  adeno- 
hypersthenia  (excessive  secretion)  is  the  most  probable 
functional  disturbance;  similar  doses  in  myasthenia  make 
matters  worse.  Lavage  is  useful  chiefly  where  there  is  stag- 
nation or  retention,  be  it  with  or  without  a  trouble  of  secre- 
tion. Only  the  mild  dynamic  affections  are  rapidly  influenced 
by  hydrotherapy.  The  magical  effects  of  a  properly-fitting 
bandage  are  only  obtained  in  displacements,  before  myasthenia 
develops.  An  ulcer-cure  may  reveal  quickly  a  suspected  ulcer, 
or,  rather,  may  confirm  the  probable  diagnosis.  The  thera- 
peutic test,  be  it  positive  or  negative  in  its  influence  on  the 
evolution  of  the  disease  or  of  the  symptoms,  is  a  valuable  aid 
in  the  diagnosis  of  difficult  cases. 

The  state  of  nutrition  is  a  revealing  sign  of  great  value. 
The  dynamic  affections,  in  spite  of  their  violent  expression, 
may  run  their  course  under  the  appearance  of  perfect  health, 
without  cachexia  or  loss  of  weight  or  strength.  The  health 
is  preserved  in  its  bloom.  But  in  the  painful  diseases  of  the 
stomach,  emaciation  may  be  so  pronounced  as  to  present  a 
special  cachectic  appearance.  This  is  the  rule  when  nutritive 
waste  remains  active,  instead  of  sharing — as  in  anorexia  ner- 
vosa— in  the  restraint  of  other  functions.  The  emaciation  of 
cancer  is  progressive.  In  chronic  gastritis  the  weight  is  pre- 
served so  long  as  the  motor  power  of  the  organ  is  intact  and 
the  intestines  are  healthy.  Should  emaciation  occur,  in  spite 
of  a  suitable  and  sufficient  diet,  there  is  stagnation,  or  reten- 
tion, or  a  complication.  Inanition,  with  its  emaciation,  weak- 
ness, and  often  discoloration  of  the  skin,  may  be  due  to  a  motor 
insufficiency  or  to  frequent  vomiting.  The  food  is  not  util- 
ized, but  destroyed  or  lost.  Rarely  can  it  be  said  that  the 
emaciation  is  the  direct  expression  of  the  disease.  But  this  is 
not  all.  The  emaciation  may  be  due  to  an  unsuitable  or  a 
starvation  diet.  Nothing  is  more  common  than  to  see  large 
quantities  of  fluid — soups,  drinks  of  all  sorts — poured  into 
a  myasthenic  stomach,  with  the  result  of  increasing  the  stag- 
nation, or  of  producing  retention.  As  soon  as  retention  be- 
gins, emaciation  sets  in.  The  diet  may  be  suitable  to  the 
disease,  but  insufficient  to  maintain  the  balance  of  nutrition. 
A  diet  which  produces  emaciation  should  be  temporary, 
purposive,  and  imperatively  demanded  ;  otherwise  it  is  in- 
jurious. 


THE  CLINICAL   HISTORY.  35 

3.  The  Present  Symptoms. — The  history  of  the  present 
trouble  being  thus  clearly  marked  out  in  its  main  lines,  the 
object  of  further  questioning  is  to  obtain  a  knowledge  of  the 
present  subjective  symptoms.  The  special  history  has  refer- 
ence to  the  past  and  to  the  present — the  genesis  and  the 
evolution  on  the  one  hand,  and  the  present  condition  or  stage 
of  the  disease  on  the  other.  We  have,  then,  the  past  symp- 
toms and  the  present  symptoms. 

To  obtain  a  knowledge  of  the  present  subjective  symptoms 
in  their  natural  relations  and  characters  it  is  a  very  good 
plan  to  ask  the  patient  to  tell  the  history  of  an  entire  day, 
beginning  in  the  morning  with  the  empty  stomach,  and 
recounting  the  symptoms  as  they  appear — what  he  did,  what 
he  ate  and  drank,  and  what  he  felt.  The  symptoms  should 
be  grouped  according  to  their  existence  during  the  period  of 
digestion  or  of  functional  rest ;  and  their  relations  to  the 
evolution  of  digestion,  more  particularly  of  the  chief  meal, 
should  be  carefully  noted. 

For  the  stomach,  the  periods  of  activity  and  repose  are 
quite  clearly  marked  physiologically ;  but  it  should  not  be 
forgotten  that  the  intestmes  also  begin  work  soon  after  a 
meal.  There  is  great  danger  of  confounding  intestinal  and 
gastric  symptoms.  On  account  of  the  mode  of  suspension 
and  fixation  of  the  intestines,  traction  symptoms  are  often 
referred  to  the  epigastrium.  The  colon  passes  above  the 
umbilicus,  and  the  duodenum,  with  coils  of  the  small  intes- 
tine, is  found  in  the  epigastric  region.  Many  so-called 
stomach  pains,  occurring  during  the  period  of  gastric  diges- 
tion, are  located  in  a  diseased  colon.  The  subjective  symp- 
toms due  to  diseased  intestines,  and  occurring  when  the 
stomach  should  be  at  rest,  may  be  referred  to  this  organ  by 
the  patient.  The  interpretation  of  the  patient  should  not  be 
implicitly  accepted,  and  we  should  be  sure  that  the  symptoms 
are  gastric.  The  neglect  of  this  precaution  may  lead  to 
error. 

The  adoption  of  a  special  set  of  questions  as  a  routine  is 
best,  in  order  to  assure  a  well-grouped  picture.  During  the 
patient's  recital  of  the  subjective  history  of  the  day,  our 
questions  should  bring  out  all  the  diagnostic  features  of  the 
important  symptoms. 

In  this  history  of  the  full  day  we  learn  the  diet — its  compo- 
sition, quality,  mode  of  preparation ;  the  relation  of  the 
symptoms  to  the  taking  of  the  food,  to  the  physiological 
action  of  the  aliment  and  drinks,  to  the  periods  of  functional 
activity  and   repose  of  the  organ,  to   the  periods  of  activity 


36  DISEASES  OE  THE  ST0AE4C//. 

and  of  repose  of  the  bocl^^  We  note  also  the  time  of 
appearance  and  the  evolution  of  the  symptoms  in  relation 
to  the  process  of  digestion  ;  the  time  of  appearance  and  the 
evolution  of  the  symptoms  as  regards  exercise,  work,  and 
repose. 

The  condition  of  the  patient  before  breakfast  may  be  of 
diagnostic  value.  The  most  characteristic  symptoms  of  some 
diseases  appear  at  this  period — such  as  the  early  morning 
nausea,  the  vomiting  of  mucus  and  bile  in  alcoholic  gas- 
tritis, and  the  morning  sickness  of  pregnancy.  In  gastric 
stagnation  and  retention,  in  morbid  sensibility  of  the  sympa- 
thetic centers,  the  person  arises  tired,  and  in  a  state  of  irri- 
tability and  of  mental  and  moral  depression.  If  there  be  no 
retention  and  no  neurasthenia,  the  period  before  breakfast 
is  the  best  during  the  day.  To  make  these  rules  valid,  an  in- 
testinal trouble  should  first  be  excluded.  The  morning  nau- 
sea, vomiting,  vertigo,  headache,  and  diarrhea,  are  frequently 
the  symptoms  of  an  intestinal  disease. 

The  traction  sensations  in  the  displacements  begin  with 
rising,  continue  throughout  the  day,  and  subside  with  the 
evening  repose. 

The  digestive  symptoms  may  or  may  not  begin  with  the 
breakfast,  depending  on  the  nature  and  the  stage  of  the  disease 
and  the  physiological  action  of  the  food.  This  small  meal 
may  be  without  bad  effect,  and  may  be  taken  as  a  rough 
measure  of  the  severity  of  the  trouble,  according  as  the  action 
is  positive  or  negative.  The  digestive  symptoms  are  more 
marked  after  a  full  meal,  and  may  occur  during  the  period  of 
the  rise,  persistence,  or  fall  of  hydrochloric  acidity. 

The  most  common  immediate  symptoms  are  the  variations 
of  general  sensations.  The  patient  becomes  conscious  of  di- 
gestion. There  may  be  only  a  feeling  of  unrest,  discomfort, 
heaviness,  pressure,  as  in  gastric  neurasthenia,  gastritis,  or 
cancer,  or  the  uneasiness  may  be  the  beginning  of  a  parox- 
ysm of  severe  pain,  which  may  slowly  develop  side  by  side 
with  the  evolution  of  secretion, — as  in  hyperchlorhydria, —  or 
which  may  become  suddenly  violent,  as  in  hyperesthesia,  or  in 
a  fresh  or  a  sensitive  ulcer.  Whether  these  severe  pains  are 
nervous  or  symptomatic  of  ulcer,  they  are  most  frequently 
encountered  in  anemic  girls.  Vomiting  as  an  immediate 
symptom,  unpreccded  by  nausea  or  pain,  is  a  reflex  motor 
nervous  affection.  When  developing  as  a  sequence  of  pain 
or  nausea  there  is  usually  a  pathological  state  of  the  mucous 
membrane.  Nervous  vomiting  is  most  frequent  in  women. 
The  motor  disturbances  of  the  stomach,  and  also  its  secretory 


THE  CLINICAL   HISTORY.  37 

troubles,  are  very  frequently  due  to  the  setting  in  motion  of  a 
diseased  intestine  from  which  the  reflex  proceeds. 

During  the  stationary  period  of  hydrochloric  acidity,  two 
characteristic  symptom-groups  may  present  themselves — the 
one  is  accompanied  by  severe  pain,  the  other  by  a  sensation 
of  heaviness,  of  pressure,  or  of  unrest.  To  the  one  belong 
gastric  neurasthenia,  chronic  asthenic  gastritis,  myasthenia ; 
to  the  other,  superacidity,  ulcer,  cancer,  and  hypersthenic 
gastritis.  Fermentation  may  complicate  either  form.  In 
the  asthenic  group,  to  the  unrest,  pressure,  w^eight,  mental 
and  moral  depression,  are  added  meteorism,  acid  reguvgita- 
tion,  and  pyrosis,  or  heartburn,  if  fermentation  be  present. 
The  symptoms  are  very  variable  in  degree  and  in  duration. 
The  hypersthenic  form  is  accompanied  by  severe  pain,  and 
by  other  signs  of  reaction  and  irritation.  The  burning  sensa- 
tion, heat,  and  drawing  together  of  the  stomach  develop  into 
a  cramp,  which  may  become  intolerable.  The  paroxysm  is  of 
variable  duration,  and  ends  with  the  passage  of  the  contents 
into  the  duodenum,  or  with  their  removal  by  vomiting.  In 
this  form  there  may  be  in  the  stomach  a  moderate  degree  of 
fermentation,  which  may  be  the  cause  of  the  state  of  irrita- 
tion ;  though  if  the  stomach  be  cleansed  and  a  test-meal 
given,  the  quantity  of  organic  acids  is  very  small.  In  the 
majority  of  these  cases  the  fermentation  and  decomposition 
are  in  the  intestines,  and  the  gastric  symptoms  are  due  to 
auto-intoxication. 

The  gastric  symptoms  occurring  only  during  the  period  of 
decline  may  be  motor,  secretory,  or  sensory.  In  the  first 
there  is  stagnation  or  retention  ;  in  the  others  there  is  abnor- 
mal secretion  or  fermentation. 

Many  of  the  gastric  symptoms  mentioned  in  the  one-day 
history  related  by  the  patient  are  common  to  several  different 
diseases  of  the  stomach.  Individually  and  out  of  their  proper 
relations  they  possess  very  little  diagnostic  or  differential 
value.  But  some  of  these  symptoms  occur  only  in  partic- 
ular diseases  of  the  stomach,  and  often  have  features  so  char- 
acteristic that  their  genesis  is  made  clear.  The  meaning  of 
the  more  frequent  of  these  symptoms,  particularly  when 
endowed  with  special  qualities,  will  now  be  briefly  discussed. 

Dysphagia. — In  dysphagia  the  trouble  may  be  in  the  power 
of  swallowing  or  in  the  permeability  of  the  esophagus.  The 
loss  of  power  to  swallow  is  due  to  paralysis  of  the  muscles  of 
deglutition  ;  paralysis  of  the  esophagus  alone  is  not  known. 
The  obstruction  of  the  esophagus  may  be  due  to  a  defect  in 
development,  to  certain  diseases  of  its  walls,  and  to  pressure 


38  DISEASES  OF  THE  STOMACH. 

exerted  at  some  point  along  its  course.  The  only  two  dis- 
eases of  the  stomach  that  produce  trouble  in  the  swallowing 
of  food,  or,  more  explicitly,  that  interfere  with  its  passage 
into  the  stomach,  are  spasm  and  organic  obstruction  of  the 
cardia. 

Heartburn. — Heartburn  is  due  to  excessive  acidity  of  the 
contents  of  the  stomach,  to  hyperesthesia  of  the  cardiac 
region  of  the  stomach,  or  to  the  regurgitation  of  the  irritant 
contents  of  the  stomach  into  the  lower  part  of  the  esopha- 
gus. It  w'as  long  supposed  to  be  a  pathognomonic  sign  of 
fermentation  in  the  stomach,  and  it  is  indeed  most  frequent 
in  fermentation  accompanied  by  the  formation  of  organic 
acids  in  considerable  quantities.  When  due  to  fermentation, 
it  is  most  commonly  excited  by  butyric  acid,  the  other  forms 
of  fermentation  rarely  producing  it.  It  is  common  in  myas- 
thenia, cancer,  and  in  the  other  diseases  of  the  stomach  accom- 
panied by  stagnation  or  retention.  Heartburn  may  also  be 
due  to  excessive  hydrochloric  acidity.  When  not  produced 
by  eating  rancid  food,  it  is  a  sign  of  either  fermentation  or  of 
excessive  hydrochloric  acidity,  hyperesthesia  and  the  regur- 
gitation of  the  normal  contents  rarely  causing  it.  Its  frequent 
presence  in  a  particular  case  possesses  some  negative  value, 
and  aids  in  the  exclusion  of  the  diseases  of  the  stomach  in 
which  fermentation  and  excessive  secretion  do  not  occur. 

Uncomfortable  Sensations. — A  sensation  of  weight  and  full- 
ness in  the  stomach  is  a  very  common  symptom.  The  sensation 
of  traction  is  also  frequent,  and  the  three  sensations  are  often 
present  together,  and  confounded  by  the  patient.  These 
sensations  possess  no  definite  diagnostic  value.  In  some 
cases  they  are  present  for  only  a  short  period  after  the  meal  ; 
in  others,  their  evolution  is  progressive  throughout  the  period 
of  digestion.  Without  possessing  an  absolute  meaning  in 
such  a  case,  the  sensations  of  weight  and  fullness  which  are 
often  associated  indicate  varying  degrees  of  myasthenia. 
The  symptoms  often  disappear  when  the  sleepy  muscle 
awakes  to  its  work,  and  the  stomach  gets  rid  of  its  contents 
by  absorption  and  peristalsis.  When  the  symptoms  persist 
through  the  unusually  long  digestive  period,  the  atony  is  more 
pronounced.  Gastric  neurasthenia  is  frequently  accompanied 
by  the  same  sensations,  which  may  be  due  in  part  to  the  in- 
creased sensitiveness  of  the  nerve-centers  during  the  period 
of  physiological  activity.  The  patient  becomes  conscious  of 
sensations  connected  with  the  state  of  the  gastric  muscle, 
which  in  health  go  unperceived.  The  neurasthenic  sensations 
are   not   so   intimately  connected    with   the  quantity  and  the 


THE  CLINICAL   HISTORY.  39 

quality  of  the  food  as  are  those  of  myasthenia  and  gastritis. 
These  sensations  may  persist  during  the  period  of  physio- 
logical rest.  There  is  then  prolapse,  a  marked  myasthenia,  or 
even  retention.  When  the  abdominal  wall  is  atonic,  the 
symptoms  are  frequently  due  to  coprostasis.  In  both  copro- 
stasis  and  prolapse  of  either  the  stomach  or  colon,  marked 
relief  is  at  once  given  by  support.  These  sensations,  in  a 
general  way,  point  to  myasthenia,  gastritis,  or  to  displacement 
of  the  stomach  or  colon  ;  they  are  due  to  the  overdistention 
of  the  muscular  layer,  to  the  stretching  of  the  nerves  or 
the  supporting  ligaments,  to  compression  of  the  sensitive 
nerves  against  adjacent  organs,  and  they  are  intensified  by 
neurasthenia. 

Pain. — Abdominal  pain  is  a  symptom  of  great  diagnostic 
value,  provided  its  qualities  and  associations  be  clearly  defined. 
Pain  in  the  abdomen  only  indicates  the  probable  location  of 
some  sort  of  disease  in  this  region  ;  it  is  a  revealing  sign  of  a 
particular  disease  only  when  its  individuality  is  exactly  and 
clearly  defined.  The  first  problem  is  to  fix  its  location  in  the 
stomach;  and  then,  through  its  qualities  and  associations,  we 
can  reason  back  to  its  particular  cause. 

Neuralgia  or  rheumatism  of  the  abdominal  wall  may  be 
mistaken  for  pain  in  the  intestines  or  in  the  stomach.  In 
muscular  rheumatism  the  pain  is  relieved  by  immobilization, 
excited  by  muscular  contraction,  and  is  often  accompanied  by 
a  slight  rise  of  the  temperature.  The  muscle  is  then  often 
contracted.  Neuralgia  follows  the  course  of  the  nerves,  and 
has  its  painful  points.  Neither  are  in  any  relation  to  the 
taking  of  food,  although  neuralgia  may  be  increased,  or  even 
relieved,  by  the  activity  of  the  stomach  ;  the  neuralgia  is  then 
associated  with  the  other  signs  of  neurasthenia.  Pressure 
may  locate  the  trouble;  in  neuralgia,  the  skin  is  sensitive;  in 
rheumatism,  deep  pressure  with  the  flat  hand  does  not  increase 
the  pain,  which  is  then  also  diffused,  corresponds  in  distribu- 
tion to  the  muscle  or  the  muscles  affected,  and  is  never  cir- 
cumscribed and  limited  to  a  very  small  area.  The  pains  of 
neuralgia  and  rheumatism  are  continuous,  and  are  subject  to 
exacerbations.  Both  may  be  associated  with  pains  in  other 
regions. 

A  pain  located  in  the  stomach  is  not  always  due  to  a  dis- 
ease of  this  organ,  which  is  often  the  seat  of  referred  pain. 
Examples  of  referred  pain  are  met  with  in  the  gastric  and  the 
intestinal  crises  of  tabes,  subacute  myelitis,  compression 
myelitis,  and  aneurysm  of  the  abdominal  aorta.  The  pain 
of  the  central  lesion — of  irritation  by  pressure — is  referred  to 


40  D/S EASES  OF  THE  STOMACH. 

the  peripheral  area  of  distribution,  in  accordance  uitli  a  well- 
known  law.  In  all  cases  of  severe  abdominal  pain  care 
should  be  taken  to  exclude  these  causes  before  attributing 
the  pain  to  a  disease  of  the  stomach. 

A  pain  which  has  the  stomach  for  its  seat,  and  which  is 
not  produced  in  the  foregoing  manner,  is  often  erroneously 
accepted  as  a  sign  of  a  local  disease  of  this  organ.  Pain 
in  the  area  of  distribution  of  one  branch  of  a  nerve  may 
have  its  origin  in  the  periphery  of  another  branch  of  the 
same  nerve.  This  is  especially  true  of  the  pneumogastric 
with  its  innumerable  connections  with  the  abdominal  sym- 
pathetic. The  pain  is  often  in  the  stomach,  when  the  disease 
is  in  the  intestines  or  elsewhere.  It  is  a  good  rule  to  sus- 
pect the  colon  whenever  the  stomach  is  the  seat  of  a  so-called 
colic. 

When  hepatic  colic  is  attended  b\'  its  typical  sj'mptoms, 
such  as  the  paroxysmal  pain,  icterus,  distention  of  the  gall- 
bladder, peritoneal  friction,  fever,  and  enlarged  or  tender  liver, 
and  when  calculi  have  been  discovered  in  the  stools,  there  is 
no  difficulty  of  diagnosis.  But  in  the  atypical  or  abortive 
attacks,  the  differentiation  may  be  more  difficult.  There  are, 
however,  many  minor  signs  which  may  reveal  the  origin  and 
location  of  the  pain. 

The  pain  of  biliary  colic  is  located  over  the  gall-bladder, 
at  a  point  three  fingers'  breadth  to  the  right,  and  the  same 
distance  above  the  umbilicus.  Here  the  pain  begins,  and 
radiates  to  the  right  into  the  back  and  shoulder,  and  to  the 
left  into  the  epigastrium,  and  over  the  whole  abdomen. 
Pressure  over  the  liver  is  painful;  pressure  over  the  uncovered 
area  of  the  stomach,  if  care  be  taken  to  avoid  the  left  lobe  of 
the  liver,  is  not  so.  The  dorsal  painful-pressure  point  is  to 
the  right  and  not  to  the  left  of  the  vertebral  column,  as  is 
the  rule  in  ulcer.  Hepatic  colic  may  be  excited  by  a  dietetic 
error,  and  is  not  altogether  independent  of  digestion.  But 
it  does  not  appear  with  regularity  after  each  meal,  or  neces- 
sarily during  the  digestive  period,  and  is  not  dependent  on 
the  physiological  action  of  the  food.  The  paroxysms  of 
hepatic  colic  are  separated  by  intervals  during  which  all 
foods  are  equally  and  perfectedly  digested.  The  causes 
which  excite  the  attack  are  not  so  palpable  as  in  the  diseases 
of  the  stomach,  but  the  attacks  seem  to  recur  almost  acci- 
dentally. In  hepatic  colic  there  is  no  typical  alteration  of  gas- 
tric secretion,  but  the  vomit  is  often  superacid.  The  diagnosis 
may  be  very  difficult  when  both  a  painful  hepatic  disease  and 
a  gastric  disease  are  at  the  same  time  present,  without  char- 


THE  CLINICAL    HISTORY.  4 1 

acteristic  symptoms.  The  attacks  of  hepatic  colic  are  rarer, 
and  recur  irregularly,  and  often  suddenly,  without  being 
accompanied  by  the  emptying  of  the  stomach.  Nor  is  he- 
patic colic  ever  relieved  by  food,  alkalies,  or  fluids.  Intestinal 
colic,  beginning  in  the  hepatic  flexure  of  the  colon,  may 
simulate  hepatic  colic. 

A  large  number  of  diseases  of  the  stomach  are  painless,  or 
can  run  their  course  without  distinct  pain.  This  is  the  case 
in  chronic  asthenic  gastritis,  in  many  of  the  dynamic  affec- 
tions involving  only  the  motor  functions,  and  in  the  milder 
cases  of  myasthenia.  Under  these  conditions  notable  pain  is 
exceptional.  Consequently,  when  pain  is  a  prominent  symp- 
tom, these  diseases  may  be  excluded. 

In  other  diseases  the  pain  is  an  accident.  Such  is  the  case 
in  myasthenia,  and  in  the  milder  cases  of  retention,  when  the 
pain  is  the  result  of  fermentation  more  dependent  on  the 
quality  of  the  diet,  or  on  an  excessive  quantity  of  food,  than 
on  the  condition  itself.  These  accidental  pains  are  the  result 
of  overdistention,  or  of  local  irritation  by  the  products  of 
fermentation. 

In  other  cases  the  pain  is  periodical,  and  it  then  appears 
either  during  the  period  of  functional  activity,  or  is  indepen-  ' 
dent  of  digestion.  In  adenohypersthenia  the  pain  develops 
with  the  increase  of  free  hydrochloric  acid,  appears  after  each 
meal,  and  is  relieved  temporarily  by  the  ingestion  of  proteids 
(milk,  meats,  eggs)  and  water.  In  hyperchlorhydria  pain  is 
not  always  present ;  when  it  is  present,  there  must  be  an 
increased  irritability,  in  addition  to  the  excessive  formation 
of  the  hydrochloric  acid ;  or  there  must  also  be  hyper- 
esthesia of  the  mucous  membrane. 

Gastric  pain  may  be  cojitimious.  Such  is  the  rule  with 
ulcer  and  advanced  cancer.  The  lesion  may  allow  no  periods  of 
entire  freedom  from  pain,  while  a  combination  of  circumstances 
increases  the  pain  during  the  period  of  digestion.  The  pain 
of  pyloric  carcinoma  is  often  severe,  but  is  even  more  per- 
sistently severe  on  account  of  the  lactic  acid  formation  and  of 
fermentation.  Of  all  the  diseases  of  the  stomach,  ulcer  and 
pyloric  cancer  are  the  most  constantly  painful. 

Gastric  pain  may  be  entirely  independent  of  abnormal 
nerves.  The  pain  is  then  due  to  compression  by  muscular 
contraction,  when  the  pain  is  acute,  and  subsides  with  the  re- 
laxation of  the  muscle  ;  or  it  is  due  to  the  overdistention  with 
gas,  in  which  case  it  is  dull,  aching,  heavy^  and  disappears 
with  the  escape  of  the  gas.  The  pain  is  the  expression  of 
the  motor  affection. 


42  DISEASES  OF  THE  STOMACH. 

The  favorite  site  of  gastric  pain  is  the  pyloric  region,  even 
when  the  disease  is  not  confined  to  this  part  of  the  stomach. 
If  this  symptom  be  carefully  studied  as  regards  its  gene- 
sis, evolution,  duration,  intensity,  location,  diffusion,  relations 
to  digestion  and  to  the  period  of  functional  repose,  to  the 
quality  of  the  food,  to  the  repose  or  activity  of  the  body  or 
the  mind,  there  is  no  other  gastric  symptom  that  possesses  so 
great  a  diagnostic  value.  Its  distinctive  features  in  the  various 
painful  diseases  of  the  stomach  will  be  found  in  the  fourth 
and  fifth  sections  of  this  volume. 

Nausea. — Nausea  is  a  frequent  symptom  of  the  diseases  of  the 
stomach.  It  sometimes  accompanies  a  dynamic  affection  of  the 
stomach,  in  which  case,  on  close  investigation,  the  cause  will 
often  be  found  to  be  a  reflex  or  an  intoxication  expression  of  an 
associated  intestinal  disease.  In  acute  and  chronic  gastritis 
nausea  mayappear  after  each  meal ;  often  also  during  the  night, 
or  early  in  the  morning.  In  the  gastric  troubles  of  the  anemias 
it  is  also  frequent.  Nausea  may  occur  when  the  stomach  is 
empty  or  during  the  period  of  gastric  digestion.  In  its  nature 
it  is  a  subjective  sensation  of  disordered  peristalsis  reflexly 
produced  through  the  vasomotor  nerves,  or  it  is  an  expression 
of  auto-intoxication,  or  of  irritation  of  the  stomach  or  the 
intestines.  The  symptom  is  most  frequent  in  the  anatomical 
diseases,  and  in  motor  troubles  accompanied  by  fermentation 
and  putrefaction.  In  cancer  it  is  a  more  frequent  symptom 
than  vomiting.  It  should  be  noted  whether  the  nausea  is 
constant  or  occurs  only  when  the  stomach  is  empty,  or  only 
during  digestion,  and  particularly  with  what  symptoms  it  is 
associated.  It  is  a  rare  symptom  in  many  of  the  diseases  of 
the  stomach,  and  is  often  present  when  the  stomach  is  not 
diseased. 

Flatulency. — Flatulency,  or  the  gaseous  distention  of  the 
stomach, 'is  a  frequent  symptom.  It  may  be  produced  in  two 
ways  :  by  the  presence  of  an  abnormal  quantity  of  gas  in  the 
stomach,  or  by  myasthenia  gastrica. 

Myasthenia  is  the  most  frequent  cause  of  flatulency, 
the  atonic  wall  yielding  to  the  natural  expansibility  of  the 
contained  gas.  This  form  of  flatulency  may  be  quickly  re- 
lieved by  a  few  eructations,  which,  however,  it  may  be  very 
difficult  to  produce  voluntarily.  There  may  or  may  not  be 
an  excessive  quantity  of  gas  in  the  stomach,  but  gas  readily 
accumulates  in  the  myasthenic  stomach. 

The  gases  found  in  the  stomach  are  swallowed,  generated 
in  the  stomach  by  chemical  decomposition  or  by  fermen- 
tation, or  are  regurgitated   from  the  intestines.     Flatulency 


THE  CLINICAL   HISTORY.  43 

may  consequently  be  a  sign  of  excessive  swallowing,  or  too 
much  saliva  (carbonates)  may  find  its  way  into  the  acid 
stomach,  or  there  may  be  too  great  a  quantity  of  carbonates 
in  the  food  and  drinks.  Effervescing  drinks  also  furnish  a 
quantity  of  gas.  The  gas  regurgitated  from  the  intestines 
may  be  formed  by  fermentation  and  putrefaction  or  by  the 
action  of  the  acids  of  the  chyme  and  of  the  organic  intestinal 
acids  on  the  carbonates  of  the  pancreatic  and  intestinal  juices. 
Carbonic  acid  gas  may  also  be  set  free  in  the  stomach  from 
the  pancreatic  juice  when  it  flows  back  into  the  stomach. 
But  the  most  frequent  cause  of  the  excessive  formation  of  gas 
in  the  stomach  is  fermentation.  So-called  gastro-intestinal 
respiration  may  be  entirely  neglected.  The  excessive  quantity 
of  gas  may  accumulate  in  the  stomach  in  spasm  and  obstruc- 
tion of  the  pylorus.  Clinically,  daily  recurring  flatulency  (not 
belching  simply)  is  a  sign  of  either  myasthenia,  pyloric  spasm, 
or  of  obstruction,  or  of  gas-forming  fermentation.  This  guide 
is  more  trustworthy  if  care  be  taken  to  keep  the  bowels  freely 
open  and  to  exclude  effervescing  drinks  and  carbonates. 

Regurgitation. — In  regurgitation  the  contents  of  the  stomach 
are  brought  up  into  the  mouth,  usually  involuntarily  and  with- 
out effort.  When  the  stomach  contents  are  returned  to  the 
mouth  to  be  again  masticated  and  swallowed,  the  condition 
becomes  a  distinct  affection  known  as  rumination. 

Regurgitation  occasionally  occurs  as  a  mere  accident  or 
episode  of  normal  digestion,  particularly  after  a  heavy  meal. 
Pathologically,  regurgitation  may  be  a  symptom  of  a  disease 
of  the  stomach,  or,  when  it  is  habitual,  constitute  an  idio- 
pathic dynamic  affection  of  the  stomach,  described  in  the 
fourth  section  of  this  volume. 

Regurgitation  is  most  frequent  during  the  period  of  diges- 
tion, but  may  occur  during  the  period  of  repose.  Occurring 
during  the  period  of  repose  of  the  stomach,  the  regurgitated 
matter  is  usually  insipid  or  slightly  acid,  and  it  consists  of- 
saliva  mixed  with  exudation  and  mucus  from  the  gastric 
mucous  membrane,  and  sometimes  also  it  is  composed  in 
part  of  the  unevacuated  remnants  of  the  previous  meal. 
This  form  of  regurgitation  is  most  frequent  in  myasthenia 
with  stagnation,  and  in  mild  cases  of  gastritis. 

Digestive  regurgitation  is  produced  by  overdistention  of  the 
stomach,  and  by  excessive  hydrochloric  and  organic  acidity. 
It  is  most  frequent  in  myasthenia  and  in  gastritis  or  gastric 
irritation.  If  the  flavor  of  the  regurgitated  matter  is  both 
bitter  and  acid,  so  as  to  set  the  teeth  on  edge,  hydrochloric 
superacidity   is    most    likely   the    cause.     If  only  bitter,   the 


44  DISEASES  OF  THE  STOMACH. 

taste  may  be  due  to  altered  bile  or  to  peptones.  If  the  regur- 
i^itated  matter  both  tastes  and  smells  sour,  there  is  probably 
fermentation.  In  cancer  of  the  esophagus  or  stomach,  and  in 
esophageal  retention,  it  ma}'  be  foul.  It  should  not  be  for- 
gotten that  regurgitation  may  be  esophageal,  and  the  matter 
consist  of  food  and  saliva  collected  above  a  constriction,  in  a 
pocket,  or  above  a  spasm  or  obstruction  of  the  cardia. 

In  pyloric  incontinence,  myasthenic  retention,  gastroptosis, 
neurasthenia  gastrica,  and  in  many  of  the  dynamic  affections, 
regurgitation  rarely  or  never  occurs,  and  the  symptom  pos- 
sesses a  negative  diagnostic  meaning. 

Vomiting. — Vomiting  may  be  a  symptom  of  a  large  number 
of  diseases,  and  does  not  necessarily  imply  that  the  stomach 
itself  is  abnormal.  Vomiting  is  almost  as  frequent  a  symptom 
of  the  diseases  of  the  intestines  as  of  the  diseases  of  the 
stomach  itself.  All  the  forms  of  vomiting  should  be  carefully 
separated  from  the  vomiting  symptomatic  of  a  disease  of  the 
stomach.  Nervous  vomiting  as  a  morbid  entity  is  rarer  than 
is  commonly  supposed.  For  the  discussion  of  this  symptom, 
and  of  hematemesis,  the  reader  is  referred  to  the  chapters  on 
Nervous  Vomiting  and  Ulcer,  respectively. 

Appetite. — The  variations  of  the  appetite,  to  be  of  diagnostic 
value,  must  be  the  expression  of  a  disease  of  the  stomach. 
Fatigue,  the  change  from  an  active  to  a  sedentary  life,  a  hot 
climate,  old  age,  monotonous  diet,  moral  strain,  physical 
pain,  are  all  accidental  causes  of  a  diminished  appetite.  The 
appetite  may  be  very  variable,  and  not  in  relation  to  the  state 
of  the  stomach,  but  to  that  of  the  brain.  The  general  or  local 
cry  for  food,  or  the  protest  against  it,  is  too  composite  to  be 
utilized  to  point  to  the  location  and  the  nature  of  the  disease 
except  under  a  particular  condition.  The  variations  are 
not  infrequently  due  to  the  coating,  the  laying  bare,  or  the 
alteration  of  the  nerves  of  taste,  in  the  diseases  of  the  mouth. 
The  appetite  is  influenced  by  the  environment,  the  mental 
and  moral  conditions,  the  state  of  nutrition,  and  by  many 
organic  and  general  diseases,  but  particularly  by  intestinal 
auto-intoxication  and  by  severe  pain.  The  appetite,  however, 
when  associated  with  symptoms  pointing  clearly  to  a  disease 
of  the  stomach,  becomes  of  use  in  diagnosis. 

A  false  hunger  may  appear  at  the  end  of  the  period  of 
digestion,  and  is  then  due  to  the  continuance  of  secretion  after 
the  stomach  is  empty. 

In  all  the  secondary  and  the  complicated  diseases  of  the 
stomach  the  character  of  the  appetite  possesses  little  diagnostic 
value,  and  does  not  indicate  the  form  of  trouble  present. 


THE  CLINICAL    HISTORY.  45 

The  appetite  also  does  not  vary  with  the  changes  of  secretion. 
In  simple  subacidity  without  fermentation  the  appetite  is  nor- 
mal. In  simple  superacidity,  however,  the  appetite  is  normal 
or  increased.  In  the  dynamic  affections,  not  assuming  a  fixed 
character  like  bulimia  and  anorexia,  or  in  the  anatomical 
diseases  growing  in  a  neuropathic  soil,  the  appetite  is  often 
rapidly  variable,  extremely  perverted,  or  easily  changed  by 
mental  impressions  or  by  a  few  mouthfuls  of  food.  But  these 
are  only  presumptive  signs  that  demand  control,  and  possess 
no  characteristics  which  can  be  considered  as  certain  or  abso- 
lute. The  rules  admit  of  many  exceptions  because  of  the 
many  associations  and  the  wide  relations  of  this  special  sensa- 
tion. 

Anorexia,  when  the  expression  of  gastric  trouble,  is  either 
nervous  or  organic.  The  nervous  form  occurs  in  the  neuro- 
pathic girl,  is  commonly  complete  for  all  food,  and  gives  no 
concern  to  the  patient.  Long-continued  anorexia,  due  to 
organic  disease  of  the  stomach,  is  a  very  grave  sign.  The 
patient  makes  every  effort  to  overcome  it,  but  without  suc- 
cess. 

In  cancer,  and  in  other  anatomical  diseases  attended  by  bac- 
terial decomposition  of  the  food,  the  appetite  is  diminished  and 
may  develop  into  disgust  for  particular  classes  of  food.  The 
appetite  grows  less  and  less  as  the  intervals  when  the  stomach 
is  empty  become  shorter  and  shorter.  The  food  against 
which  the  appetite  is  directed  belongs  to  that  class  which  is 
undergoing  fermentation  or  putrefaction.  In  ulcer  the  appe- 
tite is  maintained,  though  the  quantity  of  food  eaten  may  be 
markedly  diminished  on  account  of  pain  or  the  fear  of  pain 
associated  with  the  entrance  of  food  into  the  stomach.  In  the 
latent  form  of  ulcer  the  appetite  is,  as  a  rule,  uncommonly 
good. 

Thirst. — Thirst  is  a  less  valuable  diagnostic  sign.  It  is 
augmented  in  fermentation,  and  in  diseases  attended  by  a 
marked  diminution  of  absorption.  An  increased  desire  for 
fluids  is  often  present,  also,  in  the  secondary  gastritis  of  both 
alcoholism  and  Bright's  disease.  Thirst  is  also  a  sign  of 
poverty  of  the  fluids  of  the  body,  caused  by  increased  elimi- 
nation, by  loss  in  hemorrhage,  and  by  vomiting.  In  super- 
secretion,  the  desire  may  be  almost  irresistible.  Thirst  is 
sometimes  diminished  in  the  nervous  affections. 

The  gastric  symptoms  which  have  been  thus  far  described 
are  primary,  being  generated  and  expressed  in  the  stomach 
itself.  But  there  are  also  secondary  symptoms,  which  are 
very  frequent,  and  are  very  valuable  guides  in  the  search  for 


46  DISEASES  OF  THE  STOMACH. 

the  existence  of  a  stomach  disease.  The  secondary  symp- 
toms may  be  the  only  manifestations,  the  primary  symptoms 
sometimes  bein<j  altogether  absent. 

The  secondary  symptoms  are  generated  in  three  ways: 
some  of  them  are  reflex  and  nervous;  some  are  due  to  gas- 
tric auto-intoxication  ;  others  are  the  result  of  inanition. 

Emaciation  and  loss  of  strength  are  symptoms  of  only  a 
{t\y  of  the  simple  diseases  of  the  stomach.  The  inanition  is 
often  wholly  due  to  an  insufficient  diet,  the  little  that  is  eaten 
bein^  well  digested  and  utilized.  This  form  of  inanition  is 
seen  in  anorexia  nervosa,  in  ulcer,  and  in  the  other  painful  dis- 
eases of  the  stomach.  The  insufficient  diet  may  be  self- 
infficted  by  the  patient,  or  mistakenly  or  properly  prescribed 
by  the  physician  for  a  definite  purpose.  In  other  cases,  the 
inanition  is  the  result  of  excessive  vomiting,  or  of  the  malig- 
nant nature  or  the  advanced  stage  of  an  anatomical  disease. 
There  is  no  doubt  that  long  and  severe  suffering  may  produce 
emaciation  and  loss  of  strength,  a  fact  well  expressed  by  the 
phrase  "  the  disease  is  wearing  me  out."  But  the  most 
frequent  causes  of  inanition  of  gastric  origin  are  obstruction 
of  the  pylorus  and  myasthenic  retention.  The  food  is  im- 
perfectly digested,  is  often  periodically  lost  by  vomiting, 
and  undergoes  fermentation  in  the  stomach,  and  putrefaction 
and  fermentation  in  the  bowels.  The  pernicious  effects  of 
auto-intoxication  result,  and  the  intestines,  being  disordered 
by  the  vicious  chyme,  are  unable  to  establish  digestive  com- 
pensation. Inanition  is  also  marked  in  uncompensated  gastric 
atrophy.  Whenever  emaciation  and  loss  of  strength  are 
associated  with  a  disease  of  the  stomach,  we  should  first 
ascertain  whether  a  sufficient  quantity  of  food  is  being  eaten 
and  retained,  and  whether  the  intestines  are  healthy.  If 
such  be  the  case,  marked  inanition  is  most  likely  due  to 
carcinoma,  or  to  some  of  the  causes  of  gastric  retention. 
Long-continued  retention  and  cancer  inevitably  produce 
inanition.  Anorexia  nervosa,  vomiting,  ulcer,  and  hyper- 
sthenic gastritis  may  result  in  inanition.  The  other  dis- 
eases of  the  stomach  do  not  directly  affect  nutrition.  Con- 
sequently, the  symptom  has  both  a  negative  and  a  positive 
diagnostic  value. 

The  refle.x  nervous  symptoms  are  very  numerous,  and  are 
dependent  for  their  existence  and  their  intensity  on  the  sensi- 
bility of  the  nervous  system  and  on  the  irritation  of  the 
gastric  nerves.  The  irritable  weakness  of  the  nerve-centers 
is  produced  by  the  numerous  causes  of  neurasthenia.  The 
gastric  nerves  are  irritated  by  the  contents  of  the  stomach- 


THE  CLINICAL   HISTORY.  4/ 

products  of  fermentation,  irritant  foods  and  drinks,  prolonged 
digestion,  as  in  retention,  stagnation,  and  intemperate  eating 
— by  an  anatomical  lesion  like  ulcer,  hypersthenic  gastritis, 
cicatrices,  adhesions,  and  cancer,  and  by  the  nerve  stretching 
incident  to  developing  displacements  of  the  stomach. 

The  gastric  irritation  is  transmitted  by  the  vagosympathetic 
to  the  spine,  to  the  medulla,  to  the  brain,  and  directly  also  to 
the  heart,  lungs,  and  intestines.  In  this  manner  the  functions 
of  these  parts  become  disturbed. 

Gastric  is  much  less  frequent  than  intestinal  auto-intoxica- 
tion, because  in  the  stomach  putrefaction  is  rare,  and  absorp- 
tion is  slow  or  absent.  A  healthy  liver  is  usually  able  to  pro- 
tect the  system  against  gastric  intoxication,  but  the  functions 
of  the  liver  are,  unfortunately,  often  insufficient.  The  barrier 
against  gastric  intoxication  is  then  removed,  provided  the 
poisons  are  there  formed  in  sufficient  quantity.  That  poison- 
ous doses  are  formed  in  the  stomach  is  by  no  means  certain. 

It  is  well  known  that  chronic  putrefaction  is  rare  in  the 
stomach.  Sometimes  hydrosulphuric  acid  is  formed  in  benign 
retention,  but  in  no  greater  quantities  than  occurs  in  the 
intestines  without  giving  rise  to  intoxication.  It  is  certainly 
true  that  acute  gastric  putrefactive  auto-intoxication  does 
occur,  but  usually  only  when  the  poisons  have  been  formed 
before  the  food  enters  the  stomach.  In  every  case  of  chronic 
putrefactive  poisoning  that  has  come  under  our  observation 
it  has  proven  to  be  of  intestinal  origin,  even  where  associated 
with  gastric  retention.  It  would  be  rash  to  deny  that  tox- 
albumins  are  formed  in  the  pathological  stomach  in  sufficient 
quantities  to  produce  auto-intoxication,  but  a  theory  built  on 
such  a  supposition  is  based  on  our  ignorance. 

Gastric  fermentation,  however,  is  very  common,  but  the 
gases  and  the  organic  acids  formed  by  fermentation  are  not 
very  poisonous.  The  most  injurious  are  the  fatty  acids.  The 
others  have  only  a  local  effect. 

The  secondary  symptoms  are  very  numerous,  but  are  of 
very  little  utility  in  the  diagnosis  of  a  particular  disease  of 
the  stomach.  Certain  mental  symptoms,  disorders  of  sensa- 
tion, disorders  of  the  special  senses,  disturbances  of  the  heart's 
action,  cough,  dyspnea,  vertigo,  drowsiness,  stupor,  coma, 
headache,  neuralgia,  tetany-like  cramps,  extreme  and  inter- 
mittent muscular  weakness,  etc.,  may  be  due  to  a  disease 
of  the  stomach.  These  symptoms  are  described  in  the  sixth 
section. 


48  DISEASES  OF   TJIE   STOMACH. 

CHAPTER   II. 
THE  PHYSICAL  SIGNS. 

The  physical  signs  are  those  obtained  by  the  physician 
through  the  special  senses,  and  include  inspection,  palpation, 
percussion,  inflation,  auscultation,  and  electric  illumination, 
aided  by  special  devices.  These  objective  signs  reveal  the 
physical  deviations  from  the  normal,  and  instruct  us  concern- 
ing the  size,  the  form,  the  position,  the  distensibility,  the  mus- 
cular activity,  the  neoplasms,  and  the  sensibility  of  the  stomach, 
as  well  as  some  of  the  physical  properties  of  its  contents. 

The  physical  examination  of  the  stomach  is  a  very  old 
procedure,  but  during  the  past  decad  it  has  been  improved 
in  technic,  and  the  precise  meaning  of  each  sign  has  been 
sought  with  tireless  energy.  The  physical  examination  is  no 
less  important  than  the  more  modern  f^^nctional  exploration, 
and  has  the  unique  advantage  of  being  universally  appli- 
cable. 

The  physical  examination  of  the  stomach  is  based  on  a 
knowledge  of  its  practical  anatomy,  and  the  clinician  should 
be  well  grounded  in  this  branch.  Many  of  the  finer  anatomi- 
cal details  may  properly  be  neglected  at  the  bedside,  and 
only  those  which  have  a  practical  bearing  need  here  be 
recalled  to  mind. 

The  digestive  tube  is  a  permeable  canal,  developed  from 
the  tegumentary  layer,  beginning  with  the  mouth,  and  curling 
irregularly  through  the  body  it  ends  with  the  rectum.  The 
mouth  and  esophagus,  and  their  connecting  cavity,  the 
pharynx,  lie  above  the  abdominal  cavity,  which  extends  from 
the  under  surface  of  the  diaphragm  to  the  rim  of  the  true 
pelvis.  The  rectum,  the  lowest  division,  lies  in  the  cavity  of 
the  true  pelvis  ;  the  other  anatomical  divisions — the  stomach, 
duodenum,  jejunum,  ileum,  cecum,  colon,  and  the  sigmoid 
flexure — are  situated  in  the  abdominal  cavity. 

Fixed  points  on  the  abdominal  wall  should  be  taken  as 
the  surface  landmarks  to  be  used  in  the  investigation  of  the 
physical  changes  and  relations  of  the  abdominal  organs  and 
viscera.  The  division  of  the  abdomen  into  regions,  by  arbi- 
trary and  imaginary  lines,  is  not  free  from  objections.  We 
shall  take  the  easily  accessible  points  of  the  skeleton  and  the 
umbilicus  as  the  basis  of  abdominal  localization.  Of  these, 
the  umbilicus  is  the  only  movable  and  variable  point.     In  the 


THE   PHYSICAL    SIGNS.  49 

perfectly  normal  abdomen,  the  umbilicus  is  in  the  median 
line  in  front  and  on  a  level  with  the  tip  of  the  spine  of  the 
third  lumbar  vertebra,  a  little  below  the  center  of  a  line  join- 
ing the  ensiform  process  and  the  symphysis,  and  about  one 
inch  above  a  line  drawn  across  the  abdomen  between  the 
highest  points  of  the  iliac  crests.  Thus  is  found  the  normal 
umbilicus  or  umbilical  point. 

The  skin  over  the  epigastrium  is  supplied  by  the  sixth  and 
seventh  intercostal  nerves,  the  region  about  the  umbilicus  by 
the  ninth  and  tenth,  and  the  iliac  regions  by  the  upper  lumbar 
nerves.  The  lateral  cutaneous  nerves  (branches  of  the  lower 
seven  dorsal  and  two  upper  lumbar  nerves)  supply  both  the 
skin  and  the  muscles  of  the  abdomen.  Pathological  irritation 
of  these  nerves  contracts  the  abdominal  muscles  and  pro- 
duces pain  about  the  umbilicus. 

The  sensory  nerves  of  the  abdomen  are  in  communication 
with  the  thoracic  sympathetic  ganglia,  from  which  arise  the 
greater  and  the  lesser  splanchnics.  It  is  through  these 
nerves,  which  are  connected  with  the  cord  and  the  abdominal 
ganglia,  that  the  skin  becomes  very  sensitive,  and  the  abdom- 
inal muscles  become  contracted,  in  the  painful  diseases  of  the 
abdomen.  The  hyperesthesia  of  the  skin,  and  the  muscular 
contraction,  may  be  general  or  localized,  with  the  diffusion  or 
localization  of  the  internal  disease. 

Digestion  proper  begins  in  the  stomach — a  dilatation  of 
the  digestive  tube,  between  the  lower  end  of  the  esophagus 
and  the  beginning  of  the  duodenum  ;  in  form  it  is  irregular, 
pear-shaped,  somewhat  flattened  anteroposteriorly  ;  and  it  is 
lined  with  an  exceedingly  rich,  glandular,  internal  membrane. 
In  this  viscus  the  action  of  the  saliva  is  continued,  the  trans- 
formation due  to  the  gastric  secretion  begins,  and  a  second 
function,  that  of  absorption,  probably  commences.  The  ab- 
normal physical  variations  of  the  stomach  are  numerous 
and,  clinically,  very  important.  A  description  of  its  normal 
anatomical  relations  and  its  surface  landmarks  has  a  practical 
bearing. 

Three-fourths  of  the  stomach  lies  to  the  left  of  the  median 
line,  in  the  upper  part  of  the  abdominal  cavity,  in  contact 
and  close  union  with  the  under  surface  of  the  diaphragm. 
The  remaining  one-fourth  crosses  the  median  line  in  the  epi- 
gastrium. The  stomach  lies  in  a  nest  formed  by  the  liver, 
diaphragm,  spleen,  pancreas,  suprarenal  capsules,  intestines, 
liver,  and  abdominal  wall. 

The  stomach  is  suspended  and  held  in  position  by  its  con- 
tinuation with  the  esophagus  and  duodenum,  and  by  its  close 
4 


50  DISEASES  OF   THE   STOMACH. 

union  with  the  diaphragm  (gastrophrenic  ligament),  and  with 
the  peritoneal  folds  connecting  it  with  the  liver  (gastrohepatic 
omentum),  and  with  the  spleen  (gastrosplenic  omentum). 
The  greater  curvature  is  free,  and  rests  on  the  lesser  omen- 
tum and  on  the  intestines,  which  form  for  it  a  sort  of  support. 
The  contact  of  the  colon  and  the  stomach  may  partly  explain 
the  association  of  their  peristaltic  movements.  The  investing 
peritoneum  hangs  in  two  layers  from  its  movable  lower  bor- 
der, and  forms,  with  the  inclosed  vessels  and  the  fat,  a  more 
or  less  complete  covering  of  the  intestines.  A  few  coils  of 
the  intestines  are  left  uncovered  in  the  left  iliac  fossa,  but  the 
greater  omentum  may  be  shortened,  rolled  up,  deformed,  or 
imperfectly  developed.  It  is  attached  to  the  transverse  colon, 
and  forms  the  gastrocolic  ligament,  often  associating  the 
colon  and  the  stomach  in  their  displacements. 

The  stomach  moves  up  and  down  with  respiration,  which 
act  serves  to  keep  its  contents  in  motion.  Except  when  there 
are  abnormal  adhesions,  the  associated  movement  is  not  so 
close  that  the  stomach  can  not  be  fixed,  on  expiration,  by  the 
pressure  of  the  examining  finger.  This  peculiarity  is  made 
use  of  in  the  differential  diagnosis  of  the  tumors  of  the 
stomach. 

The  direction  of  the  long  axis  is  from  the  left  in  front  and 
above,  to  the  right  downward  and  backward,  and  corresponds 
approximately  with  a  line  slightly  curved  downward  and 
joining  the  left  nipple  with  the  tip  of  the  right  eleventh  rib. 
Pathologically,  the  acute  angle  formed  by  its  axis  with  a 
transverse  line  across  the  abdomen  may  be  increased,  and  with 
the  vertical  stomach  becomes  nearly  a  right  angle.  In  the 
deformities  of  the  stomach  the  axis  is  a  very  irregular  line. 
In  the  adult,  it  varies  in  length  from  ten  to  fourteen  inches,  in 
health. 

The  size  of  the  stomach  is  variable  and  is  dependent  on 
the  age,  and  is  largely  influenced  by  the  dietetic  habits 
of  the  person.  An  arbitrary  standard  is  valueless  as  a 
diagnostic  criterion.  The  absolute  size  has  no  definite  re- 
lation with  the  maintenance  or  loss  of  functional  power. 
A  change  of  size  between  two  dates  of  examination  is  of 
value.  The  size  can  also  be  of  diagnostic  use  when  taken 
into  consideration  with  other  signs  and  symptoms.  An 
inference  as  to  the  tone  or  the  muscular  power  of  the  stom- 
ach, drawn  from  its  size  or  from  its  capacity,  is  illogical 
and  may  be  false.  The  greatest  diameter,  measured  from 
the  cardia,  is  about  six  inches  ;  the  greatest  anteroposterior 
diameter  about  45^2  inches  ;  and  the  pyloric  end  is  about  i^/z 


THE   PHYSICAL    SIGNS.  5  I 

inches  through.  The  normal  capacity  varies  from  300  to 
2000  c.c,  in  round  numbers. 

The  descriptive  anatomy  of  the  stomach  has  a  practical 
bearing  on  pathology  and  diagnosis.  The  viscus  has  two 
openings,  two  ends,  two  surfaces,  two  curvatures,  two  divi- 
sions of  the  cavity,  and  two  localized,  sac-like  dilatations. 

The  two  orifices  are  the  cardiac,  or  esophageal,  and  the 
pyloric,, or  duodenal.  The  cardiac  opening  is  situated  on  a 
level  with  the  spinous  process  of  the  ninth  dorsal  vertebra, 
one  inch  below  the  diaphragm,  between  the  lesser  curva- 
ture and  the  beginning  of  the  upper  division  of  the  fundus, 
behind  the  cartilage  of  the  seventh  left  rib,  about  one  inch 
to  the  left  of  its  union  with  the  sternum,  and  is  covered 
by  the  left  lobe  of  the  liver.  This  orifice  is  fixed  and  held 
firmly  in  position  by  the  esophagus,  by  the  union  of  the 
peritoneal  coverings  of  the  stomach,  by  the  diaphragm,  and 
by  the  gastrophrenic  ligament.  It  is  inaccessible  to  palpa- 
tion. The  pylorus  is  on  a  level  with  the  twelfth  dorsal  ver- 
tebra and  the  ensiform  process,  lower  but  to  the  right  and 
over  the  lumbar  attachment  of  the  diaphragm,  about  two 
inches  below  the  cartilage  of  the  right  seventh  rib,  and  on  a 
line  drawn  parallel  to  and  midway  between  the  median  line 
of  the  sternum  and  the  right  border  of  this  bone.  It  touches, 
below,  the  pancreas  and  the  transverse  colon  ;  above,  the 
liver  and  the  gastrohepatic  omentum  ;  and  posteriorly,  the 
portal  vein  and  the  hepatic  artery.  It  has  no  proper  liga- 
ment or  mesentery,  is  slightly  movable,  normally,  and  its 
displacement  draws  on  the  second  part  of  the  duodenum, 
which  is  firmly  attached  to  the  posterior  abdominal  wall. 
Pathologically,  it  may  be  found  in  almost  any  part  of  the  ab- 
dominal cavity. 

The  anterior  surface  is  directed  obliquely  from  before  and 
above,  backward  and  downward,  and  is  in  relation  with  the 
left  lobe  of  the  liver,  the  diaphragm,  and  the  abdominal  wall. 
When  the  viscus  is  distended,  the  greater  curvature  rotates 
forward,  and  the  plane  of  the  anterior  surface  is  correspond- 
ingly displaced. 

The  posterior  surface  faces  backward  and  downward,  rests 
upon  the  mesocolon,  and  is  in  relation  with  the  third  part  of 
the  duodenum,  with  the  superior  mesenteric  vessels,  and  with 
the  pancreas.  Further  behind  are  the  aorta,  the  pillars  of  the 
diaphragm,  and  the  posterior  abdominal  wall.  The  lesser 
curvature  lies  beneath  the  left  lobe  of  the  liver,  is  grasped  by 
the  gastrohepatic  omentum,  faces  with  its  concavity  above  or 
posteriorly,  as  the  stomach  revolves  on  an  axis  corresponding 


52  DISEASES  OF  THE   STOMACH. 

quite  closely  with  a  line  joining  the  cardia  with  the  begin- 
ning of  the  second  part  of  the  duodenum,  and  is  on  a  level 
with  the  upper  border  of  the  first  lumbar  \-ertebra,  and  curves 
around  the  lobus  Spigelii,  the  celiac  trunk,  and  the  solar 
plexus.  Normally,  it  is  inaccessible  to  palpation.  On  it, 
near  the  pylorus,  and  about  four  inches  from  the  cardia,  is  the 
pyloric  tubercle,  the  most  frequent  starting-point  of  carci- 
noma of  the  stomach. 

The  greater  cur\'ature  begins  at  the  cardia,  curves  upward 
beneath  the  left  lung  to  the  upper  border  of  the  fifth  rib,  and 
turns  rapidly  downward  along  the  anterior  border  of  the 
spleen.  It  emerges  from  beneath  the  false  ribs  between  the 
cartilages  of  the  ninth  and  tenth  ribs,  runs  nearly  horizon- 
tally to  the  median  line,  forming  a  curve  which  marks  the  lo- 
cation of  the  lesser  cul-de-sac  on  its  way  across  the  lineaalba 
to  the  pylorus.  The  upper  part  of  the  fundus,  marked  out  by 
this  line,  is  covered  by  the  left  lung  ;  the  second  part  is  cov- 
ered by  the  false  ribs  and  by  the  abdominal  wall.  The  full 
stomach  thus  extends  from  the  fifth  rib  to  i  ^2  inches  above, 
or  even  below,  the  umbilicus. 

The  greater  curvature  approaches  the  lesser  when  the 
stomach  is  empty,  and  the  pylorus  moves  to  the  left  and  lies 
beneath  the  median  line  of  the  abdomen.  The  empty  organ 
lies  deep  within  the  concavity  of  the  diaphragm,  away  from 
the  abdominal  wall,  and  is  comparatively  inaccessible  to  physi- 
cal examination. 

The  size  and  form  of  the  stomach  are  changed  by  the 
pressure  of  the  surrounding  organs,  by  the  quantity  and  the 
quality  of  the  contents,  and  by  the  tonicity  and  the  patholog- 
ical condition  of  its  walls.  In  the  physical  examination,  the 
relation  of  the  viscus  to  the  heart,  the  lungs,  the  liver,  the 
spleen,  the  intestines,  and  the  abdominal  wall  should  be  re- 
membered. 

The  normal  stomach  is  accessible  to  physical  examination 
only  over  a  limited  area.  This  area  is  bounded  on  the  right 
by  the  left  lobe  of  the  liver,  above  by  the  heart  and  the  left 
lung,  on  the  left  by  the  spleen  and  the  colon,  below  b\'  the 
colon.  The  line  of  demarcation  begins  on  the  lower  border 
of  the  left  lobe  of  the  liver,  follows  the  greater  curvature,  or 
the  upper  border  of  the  colon,  to  the  cartilage  of  the  ninth 
rib  ;  proceeds  upward,  along  the  anterior  border  of  the  spleen, 
to  the  lower  border  of  the  sixth  rib  in  the  anterior  axillary 
line,  and  to  the  right  of  the  cartilage  of  the  seventh  rib.  The 
area  bounded  by  this  line,  and  h'ing  to  the  left  of  the  left 
costal   border,  is   known   as  the   half-moon-shaped   space    of 


THE  PHYSICAL   SIGNS.  53 

Traube.  Only  a  small  triangular  area  of  the  stomach  lies 
in  contact  with  the  muscular  abdominal  wall,  and  is  bounded 
by  the  left  costal  border,  by  the  greater  curvature,  and  by  the 
lower  border  of  the  left  lobe  of  the  liver. 

The  appearance  of  the  abdomen  varies  with  the  position 
of  the  body,  the  age,  the  muscular  development  of  the  pa- 
tient, and  the  state  of  the  contents  of  the  abdominal  cavity. 
Besides,  the  previous  contents  of  the  abdomen  leave  their 
markings  on  the  front  of  the  abdomen,  so  that  we  may  read 
on  the  abdominal  wall,  in  addition  to  the  present  state,  the 
history  of  gross  physical  changes  in  the  contents  of  the  ab- 
dominal cavity.  The  abdomen  of  a  child — on  account  of  the 
large  size  of  the  liver  and  the  stomach,  and  the  smallness  of  the 
pelvis  and  the  crude  muscular  development — presents  a  dif- 
ferent appearance  from  that  of  an  adult.  In  a  child  the  bladder 
and  rectum  are  higher  in  the  abdomen,  and  the  stomach  is  cov- 
ered to  a  greater  extent  by  the  left  lobe  of  the  liver. 

The  abdomen  of  the  healthy  and  well-developed  adult 
presents  prominences  and  depressions  corresponding  to  the 
bellies  and  ligaments  of  the  abdominal  muscles.  The  de- 
pressions are  the  median  furrow  (linea  alba),  between  the 
ensiform  cartilage  and  the  lower  fourth  of  the  abdomen,  and 
the  right  and  left  lateral  furrows  along  the  outer  borders  of 
the  recti  muscles.  The  recti  muscles  are  inclosed  in  sheaths, 
and  when  strongly  contracted  present  four  prominences, 
marked  off  by  transverse  depressions,  on  a  level  with  the 
eighth  and  ninth  costal  cartilages  and  the  umbilicus.  Neither 
these  prominences  nor  the  localized  contraction  of  the  bun- 
dles of  fibers  composing  the  muscles  should  be  mistaken  for 
physical  changes  in  the  contents  of  the  abdominal  cavity. 

I.  Inspection. — The  inspection  signs  are  remarkably  true  in 
their  signification,  but  they  are,  unfortunately,  also  very  few 
as  regards  the  diseases  of  the  stomach.  But  in  exceptional 
cases  inspection  may  rapidly  reveal  the  nature  and  the 
severity  of  the  disease. 

In  order  to  give  unity  and  method  to  the  work,  we  go  from 
the  general  surface  examination  of  the  body  to  the  inspec- 
tion of  the  mouth  and  the  throat,  the  general  inspection  of 
the  abdomen,  and,  lastly,  to  that  of  the  stomach  itself. 

The  sharp  and  quick  glance  of  the  old  clinician  is  a  power 
well  worthy  of  cultivation.  It  takes  only  a  few  moments  to 
note  the  state  of  nutrition,  the  color  of  the  mucous  mem- 
branes, the  character  of  the  patient's  expression,  the  condi- 
tion of  the  skin,  and  the  glandular  swellings — which  may  all 
be  connected  with  diseases  of  the  stomach. 


54  DISEASES  OF   THE   STOMACH. 

The  relaxation  of  the  muscular  system  may  be  a  revealing 
sign.  The  languid,  tired,  expressionless  face  of  the  niyoneu- 
rasthenic  is  well  known. 

In  the  dynamic  affections  of  the  stomach  the  general  con- 
dition may  be  satisfactory,  and  the  vivacity,  the  rotundity  of 
form,  and  the  rosy  hue  of  health  may  be  in  vivid  contrast 
with  the  nervous,  restless,  melancholy  complaints.  In  ano- 
rexia nervosa  and  in  myasthenic  retention,  however,  emacia- 
tion may  be  as  great  as  in  carcinoma. 

In  severe  diseases  the  adipose  layer  may  be  lost,  the 
abdomen  sunken  and  flabby,  the  viscera  rolling  down  into 
the  sides,  away  from  the  vertebral  column,  when  the  patient 
is  on  the  back,  and  the  skin  may  be  peculiarly  discolored,  in 
keeping  with  the  causative  troubles.  Obstruction  of  the 
cardia  and  pylorus,  carcinoma,  hypersthenic  gastritis,  uncom- 
pensated glandular  atrophy,  and  hemorrhagic  ulcer  are  the 
most  common  anatomical  diseases,  which  may  be  accom- 
panied by  cachexia.  The  sunken  eye  of  exhaustion  and  the 
pinched  and  furrowed  features  of  the  painful  diseases  should 
not  escape  notice.  An  extreme  pallor  of  the  skin  and 
mucous  membranes  suddenly  developing  in  a  painful  disease 
of  the  stomach,  accompanied  by  restlessness  but  not  by 
nausea  and  vomiting,  is  a  valuable  clinical  sign  of  a  concealed 
hemorrhage  in  an  ulcer.  The  intensity  and  the  association  of 
these  general  inspection  signs  give  some  information  con- 
cerning the  severity  and  the  possible  nature  of  the  trouble. 

The  inspection  of  the  mouth,  the  nose,  and  the  throat 
should  include  the  state  of  the  teeth  and  the  tongue,  and  of 
the  mucous  membranes  and  the  glands.  The  cause  of  the 
gastric  trouble  may  often  be  found  here. 

The  bacteria  of  the  mouth  enter  the  stomach  through 
the  swallowed  saliva  and  the  food.  A  foul  tooth  is  a  breed- 
ing nest.  The  teeth  should  be  clean  and  the  cavities  filled, 
and  losses  should  be  replaced  by  artificial  teeth.  Even  when 
the  teeth  are  good,  mastication  and  insalivation  may  be  badly 
performed.  The  carbohydrates,  when  mixed  with  saliva,  ex- 
cite the  secretion  of  the  stomach  more  freely  than  when  they 
are  swallowed  immediately  or  when  they  are  introduced  into 
the  stomach  through  the  tube.  This  result  is  due  chiefly  to 
the  physiological  action  of  the  sugar  (developed  by  the  saliva) 
on  secretion.  The  motor  work  is  also  more  easily  and  more 
rapidly  performed  when  the  food  is  finely  divided.  Decayed 
teeth  and  imperfect  insalivation  may  be  the  primitive  and  the 
sole  causes  of  gastric  symptoms.  Correction  of  these  defects 
may  be  all  the  etiological  treatment  that  the  patient  requires. 


THE   PHYSICAL    SIGNS.  55 

The  tongue  is  not  a  mirror  of  the  stomach,  as  the  ancients 
supposed.  A  clean  tongue  is  an  index  of  local  cleanliness, 
local  health,  and  the  state  of  the  secretions  of  the  mouth. 
The  coating  is  a  layer  of  morbid  secretion  or  degenerated 
cells,  and  of  bacteria.  The  secretions  of  the  mouth  are 
altered,  in  many  conditions,  by  the  diseases  of  the  stomach, 
but  not  in  a  known,  a  constant,  and  a  particular  manner.  The 
tongue  is  a  local  mirror,  which  reflects  only  that  which  comes 
over  its  surface.  A  heavily  coated  tongue  may  be  a  cause  of 
loss  of  appetite. 

The  character  of  the  secretions  of  these  parts  is  of  more 
practical  value.  These  pathological  changes  are  excited  by 
external  or  by  constitutional  causes.  Among  the  many  in- 
ternal causes,  the  diseases  of  the  stomach  form  one.  The 
nose  and  throat  changes  will  be  described  in  the  special  sec- 
tion on  the  vicious  circles  of  the  stomach.  For  the  present 
it  need  only  be  emphasized  that  the  vicious  circle  is  com- 
pleted by  the  purulent,  decomposing,  irritating  secretions 
from  these  cavities  finding  their  way  into  the  stomach  and 
exciting  trouble  there.  A  chronic  irritable  sore  throat  may 
produce  reflex  nausea  and  vomiting.  An  inspection  of  the 
mouth,  the  nose,  and  the  throat  may  reveal  the  source  of  a 
hemorrhage. 

We  begin  the  inspection  of  the  abdomen  after  the  patient 
has  been  placed  in  the  proper  position  and  light  and  the 
abdomen  and  the  greater  part  of  the  chest  have  been  laid  bare. 

The  person  lies  on  the  back,  with  the  spine  in  contact  all 
along  with  the  lounge,  the  head  comfortably  raised,  the  extrem- 
ities symmetrically  extended,  and  the  whole  muscular  system 
relaxed.  To  hold  the  legs  flexed  on  the  abdomen  requires 
effort,  and  makes  complete  muscular  relaxation  impossible. 
And  what  is  equally  objectionable  is  that  in  this  position 
they  are  in  the  way  of  the  examining  physician.  The  light 
should  fall  horizontally  from  over  the  feet  of  the  patient.  In 
this  position  the  patient  is  requested  to  breathe  quietly  and 
regularly,  and  to  relax  all  the  muscles. 

The  whole  abdomen  should  be  inspected,  and  all  the  devia- 
tions from  the  normal  should  be  noted.  But  we  must  here 
limit  our  description  to  the  inspection  signs  due  to  the  con- 
ditions of  the  stomach. 

It  need  not  be  expected  that  more  than  gross  ph}'sical 
changes  will  be  revealed  by  this  method. 

As  regards  the  stomach,  we  may  discover  by  inspection  : 
(i)  Distention  of  the  viscus  ;  (2)  contraction;  (3)  displace- 
ments; (4)  tumors;  and  (5)  peristalsis. 


56  DISEASES  OE    THE    SlOMACJl. 

1.  The  distended  stomach  ma)'  be  clearly  and  visibly  out- 
lined on  the  abdominal  wail,  if  the  wall  is  relaxed  and  suf- 
ficiently thin.  This  condition  may  be  normal  after  a  heavy 
meal,  but  is  also  frequently  pathological  and  due  to  reten- 
tion of  food  and  secretions,  swallowed  air,  and,  at  times, 
to  gas  generated  by  fermentation.  Grooves,  marking  the 
sweep  of  the  greater  and  lesser  curvatures,  may  be  seen, 
and  both  the  size  and  the  location  of  the  viscus  may  be 
thus  truly  revealed.  During  the  period  of  functional  repose 
the  stomach  is  found  distended  in  myasthenia  with  retention, 
and  in  pyloric  obstruction.  In  the  latter  condition,  the 
prominence  is  usually  much  greater  than  in  the  former,  on 
account  of  the  associated  hypertrophy  of  the  muscular  layer. 
Self-inflation  of  the  stomach  by  the  gases  of  fermentation  may 
be  observed,  but  is  of  rare  occurrence.  The  stomach  fills, 
and  then  suddenly  collapses  as  the  gas  escapes  through  the 
pylorus.  The  absence  of  visible  distention  at  the  moment  of 
examination,  naturally  does  not  exclude  the  diseases  which 
produce  it.  The  form  and  position  of  the  stomach  are  most 
easily  seen  when  the  stomach  is  full,  but  the  significance  of 
the  distention  is  determined  by  the  time  after  the  last  meal 
when  the  examination  is  made. 

2.  The  contracted  stomach  is  less  easily  recognizable  by 
inspection  than  is  the  distended  or  displaced  organ.  In 
obstruction  of  the  esophagus  and  in  cancer  of  the  cardia, 
the  stomach  may  be  very  small  and  retracted.  The  alinost 
empty,  collapsed  abdomen,  with  its  thin  covering,  presents 
a  slight  prominence,  which  extends  about  as  far  as  the 
lower  border  of  the  left  lobe  of  the  liver.  During  the 
paroxysms  of  adenohypersthenia  also  the  abdominal  wall  and 
the  stomach  may  both  be  strongly  contracted ;  but  the  face 
displays  deep  lines  of  suffering.  The  stomach  may  be  norm- 
ally very  small,  and  the  accompanying  emaciation  may  be 
due  to  diseases  elsewhere  than  in  the  stomach.  The  stom- 
ach is  often  very  small  in  scirrhus,  in  cirrhosis  ventriculi,  and 
in  chronic  starvation. 

3.  Inspection  may  give  very  truthful  information  concern- 
ing the  location  of  the  stomach.  The  small  corset-waist, 
with  the  rounded  epigastrium,  suggests  a  deformed  liver  and 
a  stomach  pressed  into  a  vertical  position.  The  lesser  cul- 
de-sac  may  then  be  the  lowest  part  of  the  stomach,  and  the 
region  just  to  the  left  of  the  median  line  and  down  to  the 
umbilicus  may  be  prominent  after  meals.  If  the  stomach  be 
prolapsed  and  full,  the  displacement  maybe  easily  recognized 
by  inspection — the   epigastrium   is    depressed,  the  abdomen 


THE   PHYSICAL    SIGNS.  57 

about  the  umbilicus — and  chiefly  to  the  left  of  it — is  promi- 
nent, and  the  grooves  of  the  greater  and  the  lesser  curva- 
tures may  be  seen  moving  slightly  with  the  diaphragm. 
If  the  stomach  be  empty,  the  displacement  may  not  be  notice- 
able, or  may  be  less  evident. 

4.  A  visible  neoplasm  of  the  stomach  is,  almost  without 
exception,  carcinoma,  and  may  often  be  seen  moving  up  and 
down  with  the  diaphragm.  The  visible  neoplasms  are  com- 
monly located  on  the  lesser  curvature,  and  are  easiest  seen 
when  so  located,  while  the  stomach  is  empty. 

It  must  not  be  imagined  that  a  visible  tumor  in  the  epigas- 
trium, which  moves  with  respiration,  is  always  a  tumor  of  the 
stomach.  Indeed,  the  visible  moving  prominence  may  not  be 
a  neoplasm.  The  transverse  colon,  when  filled  or  distended, 
may  often  be  seen  moving  up  and  down  as  a  prominence  on 
the  thin  abdominal  wall,  in  the  lower  third  of  the  line  joining 
the  ensiform  process  and  the  navel,  and  to  the  left  or  the 
right  of  the  median  line,  or  both.  This  ridge  is  often  mis- 
taken for  the  lesser  curvature,  and  a  gastroptosis  is  supposed 
to  exist;  or  it  is  mistaken  for  a  gastric  neoplasm.  The 
respiratory  movement  of  the  abdominal  organs  is  not  depend- 
ent solely  on  an  attachment  to  the  diaphragm,  but  all  of 
them  move  which  are  caught  in  the  swing  between  the  dia- 
phragm and  the  abdominal  wall,  or  are  influenced  by  the 
increase  or  the  decrease  of  intra-abdominal  pressure.  The 
closer,  however,  the  union  is  with  the  diaphragm,  the  greater 
is  the  difficulty  of  fixation  on  expiration. 

5.  The  peristaltic  movements  of  the  displaced  or  obstructed 
stomach  are  often  visible.  These  peristaltic  waves  come  out 
from  beneath  the  left  false  ribs  and  roll  across  the  abdomen 
to  the  pylorus.  When  most  violent,  the  peristalsis  may  be 
followed  by  a  visible  antiperistalsis.  The  peristalsis  may  be 
excited  when  the  organ  is  moderately  filled  with  cold  water, 
by  ether  sprayed  over  the  epigastrium,  by  faradization,  by  an 
effervescent  drink,  or,  more  conveniently,  by  a  {&\v  gentle 
strokes  with  the  tips  of  the  fingers.  Visible  peristalsis  results 
from  the  strong  efforts  of  the  stomach  to  overcome  an  ob- 
struction to  its  evacuation.  It  is  most  common  in  pyloric  or 
duodenal  obstruction,  in  gastroptosis  with  angular  constric- 
tion of  the  duodenuin,  and  it  exists  rarely  as  a  particular  dy- 
namic affection  of  the  stomach.  In  cancerous  obstruction 
of  the  pylorus  it  is  much  rarer  than  in  benign  obstruction 
with  excessive  secretion. 

The  loss  of  tone  of  the  abdominal  muscles  plays  an  impor- 
tant  part  in  the   pathology  of  the  stomach.     In  health,  the 


58  DISEASES  OF  THE   STOMACH. 

elasticity  of  these  muscles  subjects  the  abdominal  contents 
to  a  limited  degree  of  pressure,  and  affords  them  a  certain 
amount  of  support  conducive  to  their  nutrition  and  to  the 
performance  of  their  functions.  Abdominal  tension  also 
regulates  the  lymph  and  venous  circulations  of  the  abdomen. 
The  flabby  wall  e.xerts  no  pressure,  and  the  weight  of  the 
unsupported  stomach  drags  on  its  attachments.  Inspection 
may  at  once  reveal  this  half-filled  bag-like  abdomen,  which 
is  an  inspection  sign,  not  properly  of  the  stomach  itself,  but 
is  often  associated  with  the  displacement  of  this  viscus  and 
with  a  poor  abdominal  circulation.  The  inspection  of  the 
abdomen  yields  both  positive  and  negative  information. 
Some  diseases  of  the  stomach  display  no  visible  physical 
changes;  some  are  made  manifest  by  particular  inspection 
signs.  A  negative  result  of  inspection  excludes  with  proba- 
bility the  latter  class  of  diseases,  and  limits  investigation  to 
those  diseases  which  yield  no  inspection  signs  at  any  period 
during  their  evolution. 

The  stomach  may  also  be  inspected  during  its  illumination. 
For  this  purpose  the  stomach-lamp  and  the  gastroscope  may 
be  used. 

2.  Electric  Illumination  of  the  Stomach. — A  simple  and  prac- 
tical method  of  illuminating  the  stomach  was  first  devised  and 
employed  for  the  purpose  of  diagnosis  by  Einhorn.  Other 
cavities  of  the  body  had  already  been  successfully  illuminated, 
and  Milliot  had  employed  the  electric  light  to  illuminate  the 
stomach  of  the  cadaver  and  of  animals.  But  for  a  simple 
method  of  illuminating  the  human  stomach  during  life  for  the 
purposes  of  diagnosis,  we  are  indebted  to  the  inventive  genius 
of  Einhorn.  The  instrument  consists  of  an  ordinary  stomach- 
tube  with  a  small  Edison  lamp,  which  is  inclosed  in  a  thick 
glass  capsule  at  the  lower  extremity  (Fig.  i).  The  conduct- 
ing wires  run  in  the  lumen  of  the  tube  and  connect  with  a 
storage  battery.  Some  of  the  instruments  now  in  use  have 
openings  for  the  introduction  and  withdrawal  or  continuous 
circulation  of  water.  The  lamp  can  be  kept  cool  without  the 
use  of  a  continuous  current,  and  cleanliness  demands  the  use 
of  a  tube  without  openings.  The  electric  illumination  of  the 
stomach  has  been  thoroughly  studied  by  Einhorn.  by  Heryng 
and  Reichman,  by  Kuttner  and  Jacobson,  and  b\'  Meltzing, 
and  others.  Some  of  these  writers  claim  for  this  method  of 
examination  greater  accuracy  and  utility  than,  in  our  opinion 
and  experience,  it  possesses. 

Before  the  e.xamination.  which  should  be  made  in  a  dark 
room,  the   stomach    is   thoroughlv  washed   out,  unless  it   be 


THE   PHYSICAL    SIGNS. 


59 


already  empty.  Two  or  three  glasses  of  water  are  adminis- 
tered, or  introduced  through  the  tube  before  it  is  withdrawn. 
The  electric  lamp  is  next  introduced  in  the  same  manner  as 
the  ordinary  stomach-tube.  The  patient  usually  stands  during 
the  examination,  but  may  also  lie  on  the  back.  The  current 
is  turned  on  and  broken  at  short  intervals  in  order  to  avoid 
heating  the  lamp.  When  the  light  is  turned  on,  the  illumi- 
nated stomach  is  displayed  as  a  bright  area  on  the  abdominal 
wall,  shaded  by  the  recti  muscles,  crossed  by  the  veins,  and 


Fig.  1. — Ewald's  Eiiihoni  stomach-lamp. 


bounded  in  part  and  at  times  by  the  curvatures  of  the  stomach. 
After  the  general  illumination,  the  lamp  may  be  pushed 
further  on  toward  the  pylorus  and  made  to  wander  along  and 
to  locate  the  greater  curvature  as  the  tube  is  slowly  with- 
drawn.    The  water  may  be  left  in  the  stomach. 

The  information  obtainable  by  the  electric  illumination  of 
the  stomach  is  of  both  positive  and  negative  value.  By  it 
some  of  the  diseases  of  the  stomach  can  be  excluded,  while 
others,  particularly  gastroptosis,  may  be  revealed  by  it.      But 


60  DISEASES  OF   THE   STOMACH. 

the  utility  of  the  method  is  limited  in  practice,  and  the  infor- 
mation obtained  by  it  is  very  liable  to  be  misinterpreted.  It 
is  only  practicable  when  the  patient  quietly  tolerates  the 
presence  of  the  tube.  It  naturally  e.xcites  some  fear,  and 
many  patients  accustomed  to  the  use  of  the  stomach-tube 
reluctantly  consent  to  the  em[)l(:)yment  of  the  lit^ht.  There 
is  very  little,  indeed,  of  the  information  obtained  by  it  that 
is  not  given  with  greater  accuracy  by  other  and  simpler 
methods.  That  the  instruments  are  expensive  and  the 
method  of  using  them  is  but  little  understood,  can  not  be 
considered  valid  objections.  At  present,  however,  electric 
illumination  is  properly  used  to  confirm  or  control  our  con- 
clusions or  suspicions,  and  is  most  likely  to  be  valuable  in 
obscure  cases  where  it  is  advisable  to  avail  ourselves  of 
every  possible  source  of  information.  It  may  be  employed 
to  determine  the  position  and  size  of  the  stomach,  the  loca- 
tion of  the  pylorus,  and  the  existence,  origin,  and  location  of 
tumors. 

The  illuminated  area  visible  on  the  abdominal  wall  does 
not  always  represent  the  size  or  form  of  the  stomach.  The 
left  lobe  of  the  liver  .shuts  off  a  part  of  the  light,  and,  when 
enlarged,  may  be  misleading.  The  transverse  colon,  when 
filled  with  gas,  may  also  be  illuminated.  The  general  illumi- 
nation of  the  stomach  possesses  a  negative  value  when  the 
bright  area  corresponds  with  the  size  and  position  of  the 
normal  stomach.  In  gastroptosis  and  in  vertical  displace- 
ment of  the  stomach,  the  form  and  position  of  the  illumi- 
nated area  may  be  so  clear  and  characteristic  as  to  admit  of 
no  doubt.  The  result  can  be  confirmed  by  allowing  the  lamp 
to  wander  with  intermittent  flashes,  as  recommended  by 
Meltzing. 

The  electric  lamp  may  also  be  used  to  locate  the  pylorus, 
the  point  where  the  wandering  light  stops  or  turns  its  course 
backward  along  the  lesser  curvature  being  noted. 

It  is  exceedingly  rare  that  a  tumor  of  the  stomach  origi- 
nates on  or  extends  to  and  involves  the  anterior  wall,  without 
being  revealed  by  inspection,  palpation,  and  inflation.  But 
the  electric  light  may  be  used  to  confirm  a  diagnosis  of  a 
tumor  of  the  anterior  wall,  or  to  prove  that  the  anterior  wall 
is  not  thickened  by  a  neoplasm  or  by  infiltration.  It  should 
not  be  forgotten  that  fecal  masses  may  get  between  the 
stomach  and  anterior  abdominal  wall,  or  that  new  growths 
originating  in  other  parts  may  obstruct  the  light,  or  that  a 
localized  dark  spot  may  have  its  cause  in  the  abdominal  wall 
itself     Dark   spots  due   to  fecal   masses   are   not  constantly 


THE    PHYSICAL    SIGNS.  6 1 

present,  and- may,  by  manipulation,  be  removed  from  their 
position  in  front  of  the  stomach.  We  have  had  no  experi- 
ence with  Rontgen's  rays. 

The  Gastroscope. — By  means  of  the  gastroscope  constructed 
by  Leiter,  the  interior  of  the  stomach  may  be  inspected. 
Mikulicz  studied  clinically  a  number  of  cases  of  carcinoma 
and  of  ulcer  with  this  instrument.  The  use  of  the  costly 
and  complicated  metallic  instrument  is  a  severe  operation. 
Rosenheim  has  recently  modified  the  gastroscope,  but  has 
not  succeeded  in  increasing  its  utility  in  private  practice. 

3.  Palpation. — The  value  of  the  information  obtained  by 
palpation  is  conditioned  by  the  proper  performance  of  the 
work  by  fingers  which  have  been  educated  for  this  special 
purpose.  Each  palpable  organ,  in  health  and  disease,  im- 
parts to  the  hand  particular  sensations,  which  enable  us  to 
separate  one  organ  from  another,  and  to  detect  changes  in 
form,  in  size,  in  location,  in  sensitiveness,  and  sometimes  in 
texture.  By  palpation  of  the  stomach  and  intestines  it  is  also 
possible  to  obtain  some  information  concerning  the  quantity 
and  the  physical  qualities  of  their  contents. 

The  general  palpation  of  the  abdomen  should  be  made 
with  the  hand  open,  all  hand  and  arm  muscles  being  in  repose. 
In  this  natural  and  easy  position  of  the  hand  the  fingers  are 
slightly  flexed,  and  the  sense  of  touch  is  most  delicate.  The 
warm  hand  is  next  placed  on  the  abdomen,  preferably  with  the 
fingers  lying  crosswise  in  relation  to  the  axis  of  the  body  so  as  to 
appreciate  the  respiratory  movements  of  the  abdominal  organs. 
The  pressure  should  be  light  at  first,  and  then  somewhat 
firmer — the  hand  remaining  still  while  the  patient  breathes 
naturally  without  effort.  The  hand  may  next  be  slightly 
moved  back  and  forth  over  the  different  regions  of  the  abdo- 
men and  in  a  direction  at  a  right  angle  to  the  long  axis  of  the 
part  of  the  digestive  tube  contained  therein.  In  the  palpation 
of  the  particular  organs  or  of  their  parts  the  palmar  surface 
of  the  fingers  is  used.  Both  hands  should  be  educated  to  do 
the  palpation,  but  one  must  frequently  be  employed  to  bring 
a  part  within  reach,  to  fix  it,  or  to  relax  the  abdominal  wall. 
Gentleness,  ease,  method,  and  the  use  of  the  most  sensitive 
part  of  the  hand — these  are  the  requisites  of  palpation.  A 
brutal  thrusting  of  the  tips  of  the  fingers  would  cause  pain, 
would  excite  contraction  of  the  abdominal  muscles,  and 
would,  possibly,  produce  injury;  while  hard  pressure  would 
destroy  all  delicacy  of  touch. 

The  conditions  under  which  palpation  is  done  also  modify 
the  results.     The  intestines,  particularly  the  transverse  colon, 


62  DISEASES  OF   THE   STOMACH. 

should  always  be  empt\',  wlien  the  exploration  is  concerned 
with  the  stomach  alone.  The  lowered  abdominal  tension 
produced  by  evacuation  of  the  digestive  tube  and  the  bladder 
facilitates  the  examination  of  the  abdomen  ;  but  the  artificial 
evacuation  of  the  stomach  and  intestines  ma)'  not  aid  in 
the  discovery  of  their  pathological  states,  and  the  search  for 
the  cause  of  a  digestive  trouble  is  never  complete  until  after 
the  careful  palpation  of  both  these  divisions  of  the  digestive 
tube.  Consequently,  the  fir.st  examination  should  be  made 
without  preparation,  the  patient  not  being  under  the  imme- 
diate influence  of  or  recovering  from  the  effects  of  drugs. 
After  the  first  examination  the  bowels,  if  necessary,  should  be 
thoroughly  evacuated.  To  acquire  all  the  information  possible 
by  palpation  of  the  stomach,  the  exploration  should  be  made 
under  low  abdominal  tension  and  complete  relaxation  of  the 
abdominal  muscles — while  the  organ  is  digesting,  while  it  is 
empty,  and  after  inflation.  Rarely,  it  may  be  necessary  to 
conduct  the  examination  under  anesthesia. 

The  physician  should  be  comfortably  and  securely  seated 
at  the  right  of  the  patient,  facing  the  patient's  head,  and  with 
the  arms  and  the  warm  hands  free.  The  usual  position  of  the 
patient  is  that  occupied  during  inspection — straight,  relaxed, 
flat  on  the  back.  Other  special  positions  may  be  advan- 
tageous in  particular  cases.  A  very  useful  position  for  pal- 
pating the  pylorus  and  the  part  of  the  stomach  lying  beneath 
the  left  costal  border,  is  on  the  left  and  right  side  respectively, 
with  the  chest  slightly  elevated  and  with  or  without  the  legs 
flexed  on  the  abdomen.  The  knee-chest  position  and  the 
erect  position  (when  the  lower  part  of  the  abdomen  should  be 
supported)  may  also  be  employed  in  special  cases.  If  the 
patient  be  placed  on  the  back,  with  the  chest  raised  and  sup- 
ported, and  with  the  legs  strongly  flexed  on  the  abdomen  and 
supported  in  this  position,  the  deep  palpation  of  the  abdomen 
is  wonderfully  facilitated.  Whatever  position  the  patient 
assumes  during  the  examination,  his  abdominal  muscles  must 
be  inactive  and  relaxed. 

The  palpation  of  the  abdomen  should  proceed  methodically, 
by  regions  and  by  organs,  and  the  resistance,  the  tenderness,  and 
the  physical  abnormalities  of  each  area  and  each  organ  should 
be  noted.  After  the  general  palpation  of  the  abdomen,  each 
important  abdominal  organ  should  be  examined.  At  the  bed- 
side we  adopt  the  following  order:  the  large  bowel,  the 
kidneys,  the  liver,  the  spleen,  and,  finally,  the  stomach.  The 
position  and  the  excursion  area  of  the  diaphragm  should  be 
determined  by  observing  its  line  of  movement  on   the  chest- 


THE   PHYSICAL    SIGNS.  6 1 

wall,  and  by  percussion  and  auscultation  of  the  heart  and 
lungs.  We  thus  begin  the  examination  of  the  stomach  with 
a  great  deal  of  important  information  concerning  the  location 
and  physical  properties  of  the  organs  around  it. 

Tlie  palpation  of  the  stomach  will  be  discussed  under  the 
following  divisions  :  (i)  Palpation  during  digestion,  during  the 
period  of  repose,  and  after  inflation  ;  (2)  Palpation  of  the 
tumors  of  the  stomach ;  (3)  Tenderness. 

1,  The  stomach,  on  palpation,  may  not  be  found  empty 
during  the  period  of  normal  physiological  rest.  This  condi- 
tion is  always  pathological,  and  is  due  either  to  myasthenia 
or  to  obstruction,  or  to  excessive  secretion. 

The  palpation  of  the  stomach  during  digestion  may  afford 
some  information  concerning  its  position  and  the  state  of  its 
muscle.  The  hand,  gently  placed  over  the  digesting  organ, 
may  often  feel  it  alternately  contracting  and  relaxing,  in  the 
performance  of  its  churning  and  evacuating  functions.  Per- 
sistent contraction  is  a  sign  of  continuous  muscular  excita- 
tion. The  resistance  to  the  hand  may  be  continuous,  and 
associated  with  stormy  peristaltic  efforts  in  obstruction.  The 
myasthenic  organ  may  be  found  flaccid  and  non-resistant. 

Palpation  of  the  moderately  full  or  the  distended  stomach 
may  also  locate  its  position,  and  may  reveal  a  displace- 
ment. Two  methods  of  palpation  are  useful  in  locating  the 
position  of  the  stomach  :  The  organ  and  its  lower  limit,  or 
both  its  upper  and  lower  limits,  may  be  felt  by  the  full  hand 
moved  from  the  most  prominent  part  of  the  stomach  toward 
its  upper  and  lower  limits.  Sometimes  the  stomach  can  be 
felt  moving  up  and  down  beneath  the  hand  during  respira- 
tion. The  second  method  is  often  very  exact,  and  is  useful 
both  when  the  stomach  is  empty  and  when  it  is  moderately 
full.  To  locate  the  lower  border,  the  palmar  surfaces  of 
the  fingers  of  both  hands  are  placed  on  the  abdomen,  and  lie 
in  the  direction  of  the  long  axis  of  the  body  and  on  either 
side  of  the  linea  alba.  The  patient  is  told  to  breathe  deeply 
and  regularly.  Near  the  end  of  inspiration  the  fingers  are 
gently  and  firmly  pressed  downward  so  as  to  compress  what- 
ever lies  between  them  and  the  vertebral  column.  During 
expiration  the  depressed  fingers  are  all  simultaneously  drawn 
down  toward  the  symphysis.  The  procedure  is  repeated,  now 
higher  and  now  lower,  until  the  point  where  the  lower  edge 
of  the  stomach  is  felt  to  slip  up  beneath  them  during  ex- 
piration is  reached.  The  same  method  may  be  employed 
while  the  diaphragm  is  at  rest.  To  locate  the  upper  border 
when    it    is    made    accessible    to    palpation  by   gastroptosis, 


64  DISEASES  OF   THE   STOMAL//. 

the  fingers  should  point  toward  the  symphysis  and  be 
drawn  toward  the  ensiforni  process  while  the  abdomen  is  in 
repose.  The  edge  may  thus  be  felt  to  slip  suddenly  from 
beneath  the  fingers ;  or  the  fingers  may  be  placed  as  in  the 
method  of  locating  the  lower  border,  and  gently  but  rapidly 
drawn  from  their  point  of  pressure  on  the  spinal  column 
toward  the  symphysis  pubis,  during  expiration.  The  ridge 
of  the  lesser  curvature  may  sometimes  be  detected  in  this 
manner.  When  the  stomach  is  empty,  the  examination  is 
facilitated  by  the  administration  of  an  effervescent  drink. 
The  differentiation  of  the  stomach  from  the  pancreas  and 
from  the  transx'erse  colon  presents  no  difficulty  to  one  con- 
versant with  anatomy  and  experienced  in  abdominal  palpa- 
tion. The  pancreas,  if  accidentally  felt  (apart  from  its  location 
and  its  small  width  and  thickness),  can  be  easily  differen- 
tiated by  its  immobility  and  absolute  stillness  during  respira- 
tion. Whenever  one  border  of  the  transverse  colon  can  be 
felt,  the  other  border  can  be  felt  also,  and  the  colon  is  nearly 
always  narrower  than  the  stomach.  In  case  of  doubt,  the 
other  methods  of  locating  the  lower  border  of  the  stomach 
and  of  differentiating  the  colon  from  the  stomach  can  be  used. 
One  of  the  surest  is  the  palpation  of  the  tube  when  introduced 
into  the  stomach. 

Leube  introduced  a  method  of  locating  the  lower  border 
of  the  stomach  which,  however,  he  now  no  longer  employs. 
A  stiff  sound  is  introduced  into  the  stomach,  and  pushed  on 
until  the  resistance  of  the  lower  curvature  is  felt.  By  palpa- 
tion through  the  abdominal  wall  the  lower  end  of  the  sound 
is  located.  Meltzing  allows  the  electric  light  to  wander  along 
the  curvatures  of  the  stomach,  and  its  visible  line  of  march  is 
thus  located.  Turck  uses  a  revolving  sponge,  which  is  pal- 
pable and  sometimes  visible  along  the  line  of  its  march  in  the 
same  manner.  Boas  recommends  the  employment  of  the 
stomach-tube,  the  position  of  which  is  located  by  j)alpation  as 
it  glides  and  lines  itself  along  the  greater  curvature.  These 
methods,  on  account  of  the  distensibility  and  easy  displace- 
ment of  the  borders  of  the  stomach  by  pressure,  may  give  too 
large  an  area,  but  are  sufficiently  accurate  for  all  practical 
purposes,  and,  when  the  tube  is  tolerated,  are  most  excellent 
control  methods.  The  spiral  stilet  pyloric  sound  of  Kuhn 
(Fig.  2)  is  better  than  the  simple  stomach-tube;  and  both  of 
these  instruments,  when  they  are  employed  for  locating  the 
greater  curvature,  the  pylorus,  and  the  tumors  of  the  stomach 
by  palpation,  and  for  differentiating  the  tumors  of  the  stom- 
ach  from   the  tumors   of  adjacent  organs,  should   be   about 


THE   PHYSICAL   SIGNS. 


65 


100  cm.  long.  It  is  rarely  necessary  to  introduce  more  than 
75  cm.  of  the  tube ;  and  the  examination  should  be  made 
when  the  stomach  is    empty  and   when  it  is   full,  when  the 


Fig.  2.— A,  Kuhn's  pyloric  sound.  The  spiral  metallic  stilet  (a)  is  to  be  introduced  into 
the  stomach-tube  {b),  made  of  Jacques'  rubber  ;  B,  Kuhn's  balloon  sound.  The  stilet  (jr) 
fits  into  the  rubber  tube  and  inflatable  bulb  (jc). 


patient    is   lying    flat    on   his   back    and   when    in    the    erect 
position. 

2,  Not  all  the  palpable  tumors  of  the  stomach  are  malignant. 
They  may  be  due  also  to  ulcer,  with  adhesions  and  exudation 

5 


66  DISEASES  OF  THE  STOMACH. 

to  simple  hypertrophy  of  the  pylorus,  and,  very  rarely,  to 
benign  neoplasms.  A  very  valuable  differential  sign  of  a 
gastric  tumor  is  that  it  may  be  fixed  by  the  palpating  fingers 
during  expiration.  But  when  adhesions  have  been  formed  to 
the  diaphragm,  or  to  the  organs  closeU'  bound  to  it,  this  differ- 
ential characteristic  is  lost.  The  ga.>;tric  tumors,  like  those 
of  all  organs  attached  to  the  diaphragm,  move  up  and  down 
with  this  muscle,  in  respiration.  The  tumors  of  the  stomach 
always  feel  much  smaller  than  they  are,  and,  though  fixable 
on  expiration,  readily  slip  up  when  the  pressure  of  the  fingers 
is  lessened. 

A  negative  result  of  palpation  in  a  case  of  suspected  gastric 
tumor  means  very  little.  The  tumors  of  the  cardia  can  not 
be  felt.  The  same  is  true  when  they  are  small,  wherever 
situated,  and  when  the  conditions  are  not  favorable  to  a 
thorough  examination.  Cancer  may  be  diffused,  and  may 
thus  escape  detection.  Tumors  situated  posteriorly  are 
never  palpable,  unless  the  viscus  be  empty.  The  tumors  of 
the  lesser  curvature  are  turned  back,  out  of  reach,  when  the 
stomach  is  distended,  and  may  be  drawn  up  beneath  the  bony 
thora.K  by  adhesions  to  the  diaphragm.  The  tumors  of  the 
pylorus  may  just  as  often  be  felt  elsewhere  as  at  the  point 
marking  the  situation  of  the  normal  pylorus.  These  tumors 
may  move  only  with  the  diaphragm,  or  may,  rarely,  be  carried 
by  the  fingers  into  almost  any  part  of  the  abdomen. 

It  is  often  difficult  to  decide  whether  the  tumor  belongs 
to  the  pylorus.  Inflation  of  the  stomach  may  clear  up  the 
difficulty.  A  better  and  simpler  way  is  to  give  the  patient  a 
glass  of  water,  and  to  liold  the  fingers  gentl\'  on  the  pylorus, 
when  the  part  will  grow  alternately  soft  and  resistant,  except 
when  the  pylorus  is  converted  into  a  hard  ring  by  an  infil- 
trating scirrhus,  and  the  water  can  be  felt  bubbling  through. 
A  spurting  sound,  somewhat  like  that  at  the  cardia  on  swal- 
lowing, may  also  be  heard  with  the  stethoscope,  and  is  loudest 
directly  over  the  pylorus.  Or  the  pylorus  may  be  located  by 
Kuhn's  pyloric  sound. 

The  palpation  and  localization  of  the  tumors  of  the  stomach 
may  be  wonderfully  facilitated  by  the  employment  of  Kuhn's 
or  Schreiber's  balloon  sounds,  which  are  useful,  also,  for 
locating  the  stomach  and  the  cardia,  and  for  detecting 
the  bilocular  stomach  and  the  incomplete  division  of  the 
stomach  into  two  cavities  by  deformities  or  by  compression. 
The  little  balloon  is  inflated  to  a  suitable  size  after  the  pas- 
sage of  the  cardia  or  after  the  passage  of  the  constriction  of 
the  body  of  the  stomach,  and  the  cardia  or  the  constriction 


THE   PHYSICAL    SIGNS.  6y 

is  detected  and  located  in  the  manner  employed  for  the  de- 
tection and  location  of  a  urethral  stricture. 

3.  Epigastric  tenderness  may  or  may  not  be  due  to  gastric 
disease. 

It  is  very  common  to  find  the  abdominal  muscles  sore  after 
straining  or  unwonted  use  of  them.  The  soreness  corres- 
ponds with  the  area  of  the  muscle,  and  not  with  the  distribu- 
tion of  the  cutaneous  nerves. 

Increased  sensibility  of  the  skin  over  the  epigastrium,  and 
corresponding  with  the  distribution  of  the  cutaneous  nerves, 
reflects  a  morbid  sensibility  of  the  gastric  mucous  membrane, 
and  is  a  very  valuable  palpation  sign.  The  route  of  the 
reflected  hyperesthesia  passes  through  the  vagosympathetic 
ganglia  and  the  cord. 

Epigastric  tenderness  is  frequently  due  to  the  sensitive 
left  lobe  of  the  liver,  the  whole  of  which,  or  only  its  border, 
may  be  painful  on  pressure.  The  tender  area  or  line  will  be 
found  to  correspond  with  the  size  and  the  form  of  the  left  lobe, 
and  will  at  once  suggest  its  cause.  The  other  lobes  of  the 
liver  may  be  tender  ;  the  area  of  the  stomach  itself  is  not  so. 
Epigastric  tenderness  may  be  due  to  an  irritable  solar  plexus. 
The  pain  on  pressure  is  somewhat  dull,  unnerving,  and  con- 
siderably affects  the  circulation.  The  tenderness  of  the  plexus 
is  greatest  during  digestion,  and  may  disappear  during  the 
period  of  repose. 

The  tenderness  may  be  in  the  duodenum.  This  is  the  case 
in  duodenitis,  duodenal  ulcer,  and  duodenal  stagnation.  The 
point  is  near  the  middle  of  the  right  costal  border,  and 
gentle  but  firm  pressure  should  be  exerted  upward  and  out- 
ward and  backward.  Phillip  located  this  tender  point  in  the 
pylorus.  Glenard  places  it  in  the  quadrate  lobe  of  the  liver. 
It  may  also  be  in  the  head  of  the  pancreas  or  in  the  choleduct. 
In  gastroptosis,  under  favorable  circumstances,  the  pancreas 
may  be  felt  as  a  flat,  thin,  immobile,  transverse  body,  which 
should  not  be  confounded  with  the  transverse  third  part  of  the 
duodenum,  which  is  lower.  Pressure  on  the  pancreas,  when 
thus  found,  is  often  painful.  Here  the  tender  point  of  Phillip 
may  also  have  its  seat. 

The  colon  passes  along  the  lower  border  of  the  stomach, 
and  the  pain  on  pressure  located  therein  should  not  be  con- 
founded with  that  of  the  stomach. 

Diffuse  gastric  tenderness  maybe  muscular,  as  after  gastric 
spasm,  or  may  be  due  to  anatomical  disease  of  the  lining  mem- 
brane, to  cancerous  infiltration,  to  perigastritis,  and,  possibly, 
to  gastralgia.     This  diffuse  gastric  tenderness  possesses  a  very 


68  DISEASES  OF  THE  STOMACH. 

indefinite  meaning.  Tliis  is  not  true  of  the  very  sharply 
limited,  small,  often  exceedingly  tender  spot  located  on  or 
near  the  median  line,  below  the  xiphoid  process,  and  associ- 
ated with  a  circumscribed  tender  spot  to  the  left  of  the  twelfth 
dorsal  vertebra.  These  palpation  signs  are  most  common  in 
ulcer,  but  they  may  also  be  due  to  tender  adhesions,  and, 
rarely,  to  carcinoma.  The  ulcer  pain  may  be  excited  by  a 
pressure  of  one  or  two  pounds;  that  of  the  other  painful  dis- 
eases of  the  mucous  membrane  of  the  stomach  requires  from 
three  to  ten  pounds.  The  algesimeter  of  Boas  is  a  very  use- 
ful in.strument  for  measuring  this  difference  with  exactness. 

Gastric  carcinoma  may  also  be  exquisitely  painful  on  press- 
ure, and  this  quality  may  aid  us  in  differentiating  it  from 
painless  tumors,  true  or  false. 

Palpation,  like  inspection,  yields  both  positive  and  negative 
information,  which  may  reveal  a  disease  or  a  group  of  diseases 
of  the  stomach. 

4.  Percussion. — The  area  of  the  stomach  which  can  be 
marked  out  by  percussion  is  dependent  not  only  on  the  size, 
the  position,  and  the  contents  of  the  stomach,  but  also  on 
changes  in  the  surrounding  organs,  the  liver,  the  lungs,  the 
iieart,  the  pleura,  the  spleen,  andthe  colon.  Large  abdominal 
tumors  would  alter  its  percussion  boundaries.  Consequently, 
the  abnormal  percussion  signs  should  be  used  with  circum- 
spection in  implicating  the  stomach  as  the  diseased  part. 

In  percussing  the  stomach,  we  locate  successively  the  upper, 
lower,  right,  and  left  borders,  and  note  the  occurrence  of 
pathological  sounds  within  this  area.  The  percussion  limi- 
tation of  the  stomach  should  be  attempted  only  when  the 
stomach  is  moderately  full  of  gas.  If  the  stomach  be  empty 
and  normal,  it  is  withdrawn  into  the  concavity  of  the  dia- 
phragm, and  the  transverse  and  splenic  fle.xure  of  the  colon 
occupies  the  vacated  spot  in  the  epigastrium.  If  distended, 
the  stomach  limits  will  be  too  high  or  too  low. 

The  location  of  the  upper  border  is  found  by  moderately 
deep  percussion  from  above  downward.  According  as  the 
percussion  is  deep  or  shallow  will  the  result  be  slightly 
different,  and  the  transition  from  pulmonary  resonance  and 
from  dulness  to  gastric  tympanicity  will  be  more  or  less 
abrupt. 

If  the  organs  of  the  thorax  are  healthy  and  the  stomach  is 
moderately  distended  with  gas,  the  normal  superior  percus- 
sion limit  is  appro.ximately  the  following  :  In  the  left  para- 
sternal line,  behind  the  fifth  rib;  in  the  clavicular  line,  in  the 
fftli  intercostal  space;  in  the  anterior  axillary  line,  which   is 


THE    PHYSICAL    SIGNS.  69 

the  furthest  extension  of  the  stomach  to  the  left,  in  the  seventh 
interspace. 

The  sh'ght  displacements  of  the  upper  border  are  of  little 
value  in  the  diagnosis  of  the  diseases  of  the  stomach.  The 
only  diseases  of  the  stomach  which  modify  greatly  the  posi- 
tion of  the  upper  border  are  gastroptosis,  upward  displace- 
ment, and  left  subphrenic  abscess  complicating  an  ulcer  or  a 
malignant  growth.  In  gastroptosis,  the  lesser  curvature 
descends  simultaneously  with  the  fundus  and  with  the  greater 
curvature.  The  limit  may  be  lowered  by  left  pleurisy  with 
effusion,  pneumonia,  emphysema,  or  pneumonia  of  the  left 
lower  lobe.  It  may  be  raised  by  conditions  causing  ascent  of 
the  left  cavity  of  the  diaphragm.  The  upper  percussion 
border  is  also  modified  by  changes  in  the  size  of  the  left  lobe 
of  the  liver,  and  by  the  gaseous  distention  of  the  stomach. 

The  location  of  the  lower  limit  of  the  stomach  by  percus- 
sion is  more  difficult  than  the  location  of  the  upper  bound- 
ary. We  begin  with  very  light  percussion  (the  patient  lying 
on  the  back,  as  usual)  in  the  prolongation  of  the  left  para- 
sternal line  near  the  symphysis,  and  gradually  move  upward, 
noting,  if  possible,  the  transition  from  the  sound  over  the 
colon  to  that  over  the  stomach.  There  is  often  a  narrow 
transition  area  over  which  the  two  sounds  are  mixed,  and 
may  be  separated  and  different  notes  produced  by  closing  or 
extending  the  gently  percussing  fingers  at  the  moment  of 
contact  with  the  one  resting  on  the  abdominal  wall.  The 
supposed  gastric  sound  should  then  be  followed  to  the  left 
and  right,  to  see  if  it  corresponds  with  the  form  and  the 
location  of  the  stomach  or  the  colon. 

Special  devices  have  been  found  useful  and  necessary  in 
the  delimitation  of  the  lower  border  by  percussion.  One 
consists  of  the  introduction  of  fluid  or  gas  into  the  stomach 
or  colon,  so  as  to  produce  a  corresponding  difference  in  the 
percussion  note.  If,  for  example,  the  stomach  and  the  colon 
give  a  clear  and  a  similar  tympanitic  sound,  we  first  note  this 
fact  in  the  erect  and  in  the  recumbent  position.  We  next 
give  the  patient  a  glass  of  water,  and  mark  in  the  erect 
position  the  area  or  line  of  diminished  clearness,  which  again 
becomes  clear  in  the  recumbent  position.  Or  a  quart  of  water 
may  be  introduced  into  the  stomach  through  the  tube,  the 
area  of  dulness produced  thereby  located,  and,  in  order  to  prove 
that  the  dulness  is  due  to  the  contents  of  the  stomach,  the 
water  is  again  removed  by  expression  (Piorry,  Penzoldt). 
Some  notion  of  the  tonicity  of  the  stomach  in  myasthenia 
may  be  gained  by  giving  the  water  in   successive  half-glass- 


JO  DISEASES  OF  THE  STOMACH. 

fills,  and  by  noting  the  descent  of  the  line  of  diminished 
cle.irness  (Dehio,  Boas).  Whatever  devices  may  be  employed, 
the  percussion  signs  are  not  so  markedly  changed  as  we 
should  anticipate,  and  often  leave  us  in  doubt.  The  descent 
of  the  normal  lower  boundary  means  that  the  stomach  is 
enlarged,  distended,  myasthenic,  or  displaced.  Two  or  more 
of  the  conditions  may  be  combined  in  a  particular  case,  and 
the  differentiation  must  be  made  by  other  methods. 

The  right  limit  of  the  percussion  area  of  the  stomach  may  be 
most  easily  marked  out  by  proceeding  with  light  percussion 
from  over  the  tympanitic  stomach,  along  parallel  lines,  to  the 
right.  The  points  of  beginning  dulness  mark  the  right  bor- 
der accessible  to  percussion.  The  position  of  this  border 
varies  with  the  size  of  the  liver. 

If  the  liver  be  normal  in  size  or  small,  a  small  area  of  gas- 
tric resonance  may  be  located  across  the  median  line,  below 
the  left  lobe.  In  myasthenia,  or  in  enlargement  from  obstruc- 
tion, the  lesser  cul-de-sac  may  extend  downward,  and  further 
to  the  right.  In  vertical  displacement,  the  percussion  area 
does  not  cross  the  median  line. 

The  left  percussion  border  is  displaced  chiefly  by  enlarge- 
ment of  the  spleen. 

The  changes  in  the  percussion  note  over  the  normally 
tympinitic  area  of  the  stomach,  uncovered  or  unoccupied  by 
a  healthy  or  a  diseased  adjacent  organ,  may  be  due  to  the 
contents  of  the  stomach,  or  to  a  tumor. 

It  is  quite  characteristic  of  the  moderately  filled  myasthenic 
stomach  that  the  percussion  sound  should  vary  greatly,  both 
with  the  position  of  the  patient,  and  with  the  peristalsis  of 
the  organ.  The  well-toned  normal  muscle  contracts  on  its 
contents,  and  maintains  a  notable  degree  of  intragastric  pres- 
sure. The  normal  tonicity  tends  to  maintain  the  form,  de- 
spite changes  of  position  of  the  body.  The  flabby,  myas- 
thenic stomach  alters  its  form,  in  obedience  to  the  laws  of 
gravity,  and  to  the  slight  pressure  of  neighboring  parts. 
These  variations  may  be  noted  during  digestion,  or  during 
the  period  when  the  stomach  should  be  empty. 

During  digestion  there  is  more  or  less  dulness  over  the 
fundus,  from  one  to  five  hours  after  a  meal,  in  accordance 
with  the  quantity  and  quality  of  the  food  taken.  In  the 
strong  stomach,  the  left  or  upper  boundaries  move  to  the 
right  or  downward,  as  the  patient  rolls  to  the  right  side  or 
stands  erect.  Under  the  same  circumstances,  the  fundus  of 
the  myasthenic  stomach  becomes  tympanitic,  but  in  the  erect 
position   the  lower  boundary  sinks  notably. 


THE    PHYSICAL    SIGNS.  /I 

The  percussion  note  may  vary  without  change  of  the 
position  of  the  patient.  A  point  now  dull  becomes,  after  a 
{q\v  minutes,  tympanitic,  and  vice  versa.  The  phenomenon  is 
due  to  peristalsis,  usually  in  a  flabby,  myasthenic  stomach 
partly  filled  with  fluid  and  gas. 

Before  dismissing  the  subject  of  percussion,  we  wish  to 
make  an  emphatic  protest  against  the  too  great  value  as- 
cribed to  the  mere  size  and  to  the  percussion  limits  of  the 
stomach.  Much  of  the  time  spent  in  the  exact  location  of 
its  borders  is  wasted.  The  capacity  of  the  stomach  bears  no 
relation  whatever  to  its  functional  efficiency.  The  location 
of  the  borders  may  enable  us  to  say  whether  the  stomach 
is  larger  or  smaller  than  the  average  ;  but  we  can  not  say 
whether  the  size  is  or  is  not  normal  for  the  individual  under 
examination.  The  limits  of  the  stomach  are  changed  by  a 
few  of  the  pathological  conditions  of  the  stomach  itself,  such 
as  displacement,  obstruction,  distention,  stenosis  of  thecardia, 
and,  sometimes,  myasthenia.  Concerning  these,  percussion 
may  only  give  vague  suggestions  that  must  be  controlled 
and  complemented  ;  but  often  the  limits  of  displaced  organs 
may  be  located  with  precision,  as  when  the  lesser  curvature, 
on  account  of  gastroptosis,  emerges  from  beneath  the  left  lobe 
of  the  liver,  or  when  the  wandering  pylorus  is  dragged  down 
by  a  neoplasm. 

The  percussion  signs  when  negative  are  valueless,  in  this 
respect  differing  from  those  obtained  by  inspection  and  pal- 
pation. When  positive,  they  are  inaccurate.  The  lower  bor- 
der, being  distant  from  the  abdominal  wall,  is  always  lower 
than  percussion  places  it.  The  right  and  left  borders  can  not 
be  even  approximately  determined.  The  contraction  and 
thickness  of  the  abdominal  wall  modify  the  percussion  note. 
These  signs  are  approximately  accurate  only  when  the 
stomach  is  just  full  of  gas  without  distention.  Of  more 
importance  than  the  mere  position  of  the  borders  are  the 
difference  in  their  location  when  the  stomach  is  empty  and 
when  it  is  full,  and  the  variations  in  the  distance  separating 
the  upper  and  the  lower  borders  measured  on  the  parasternal 
line. 

The  distance  from  the  cardia  to  the  greater  curvature  may 
be  measured  fby  the  method  of  Purjesz.  The  external  end 
of  the  stomach-tube  is  connected  with  a  manometer.  The 
passage  of  the  tube  through  the  cardia  and  its  entrance  into 
the  stomach  are  marked  by  a  sudden  change  from  negative 
to  positive  pressure.  At  this  moment  a  mark  is  made  on  the 
tube  where  it  crosses  the  incisor  teeth,  and  it  is  then  pushed 


72  DISEASES  OF  THE  STOMACH. 

on  until  the  resistance  of  the  greater  curvature  is  felt.  The 
length  of  the  tube  required  to  extend  from  the  cardia  to  the 
greater  curvature  measures  the  distance  between  them. 

More  accurate  than  simple  percussion  is  auscultatory  per- 
cussion, which  may  be  performed  in  two  ways  :  The  binaural 
stethoscope  may  be  fixed  over  the  triangular  space  where  the 
full  stomach  comes  in  contact  with  the  abdominal  wall,  and 
percussion  may  be  performed  along  eccentric  lines  running 
in  ever}'  direction  until  the  sound  is  lost ;  or  the  stethoscope 
may  be  moved  along  these  lines  while  the  percussion  is  being 
performed  over  the  triangular  space.  Combined  percussion 
and  auscultation  are  not  likely  to  be  employed  except  in  ob- 
scure cases,  when  percussion  signs  are  more  likely  to  deceive 
than  to  instruct. 

5.  Inflation. — Inflation  of  the  stomach  is  a  device  which 
may  render  much  more  exact  the  results  of  inspection,  of 
palpation,  and  of  percussion. 

The  older  method  consists  in  the  administration,  succes- 
sively, of  tartaric  acid  and  of  bicarbonate  of  soda,  the  COo 
set  free  in  the  stomach  distending  the  organ.  Some  use  as 
much  as  one  dram  of  the  acid,  and  a  little  more  of  the  bi- 
carbonate of  soda.  These  large  doses  ma\'  produce  discom- 
fort, but  may  be  required  to  fill  stomachs  of  more  than  aver- 
age capacity.  It  is  seldom  advisable  to  use  more  than  one- 
half  a  dram  of  tartaric  acid,  dissolved  in  one-third  of  a  glass 
of  sweetened  water,  and  35  grs.  of  the  bicarbonate,  also 
dissolved  in  a  small  quantity  of  water,  when  the  object  is  to 
determine  the  boundaries  of  the  stomach  by  percussion.  But 
to  render  the  stomach  visible  and  easily  palpable,  the  large 
doses  of  the  tartaric  acid  and  soda  are  necessary.  The  pa- 
tient drinks  the  acid  solution,  waits  about  one-half  of  a  min- 
ute until  it  has  all  been  emptied  into  the  stomach,  and  then 
swallows  the  solution  of  the  bicarbonate  of  soda,  closes  the 
mouth,  lies  flat  on  the  back,  and  breathes  quietly.  The  acid 
requires  about  one-ninth  more  of  the  bicarbonate  of  soda 
for  saturation. 

The  second  method  consists  in  the  introduction  of  air  into 
the  stomach  through  the  tube.  Bouveret  suggests  that  the 
physician  apply  his  mouth  to  the  end  of  the  tube  and  thus 
inflate  the  stomach,  but  this  method  of  inflation  is  objection- 
able on  grounds  of  cleanliness,  and  the  physician's  mouth  is 
in  danger  of  becoming  filled  with  regurgitated  stomach-con- 
tents. The  tube  being  introduced,  the  bellows  part  of  a 
double-bulb  atomizer  is  attached  to  it  by  means  of  a  piece 
of  glass  tubing,  and  the  stomach   of  the. patient  (who  lies  on 


THE   PHYSICAL    SIGNS. 


73 


the  back)  is  then  very  slowly  and  watchfully  distended  with 
air.  The  inflation  should  be  at  once  stopped  if  the  patient 
show  signs  of  distress,  even  though  the  stomach  has  not 
been  well  distended. 

Each  method  has  its  advantages  and  disadvantages.  The 
inflation  with  air  is  under  the  control  of  the  operator,  and 
the  air  can  be  increased  or  diminished  and  the  operation  sus- 
pended or  repeated  at  will.  But  the  method  is  greatly  limited 
by  the  necessity  of  employing  the  tube,  and  the  operation 
should  never  be  attempted  before  the  patient  has  lost  all  fear 


Fig.  3. — Strauss'  apparatus  for  lavage  and  inflation. 


and  has  learned  by  experience  to  tolerate  the  tube.  The  dis- 
tention with  generated  gas  is  more  universally  applicable,  but 
is  uncontrollable,  and  may  be  unsatisfactory.  Both  methods 
may  be  rendered  useless  by  the  rapid  evacuation  or  passage 
of  the  gas  or  air  into  the  duodenum.  When  the  pylorus  is 
incontinent,  the  gas  bubbles  through  it  rapidly  and  con- 
tinuously. The  cause  of  the  failure  of  the  pylorus  to  close 
properly  (atony,  paresis,  infiltration,  particularly  by  cancer, 
and  peripyloric  adhesions)  may  not  be  revealed  by  this 
method  and  may  be  left  an  open  question  to  be  answered  by 


74  DISEASES  OF  THE  STOMACH. 

Other  signs  and  by  the  clinical  history.  More  commonly  the 
gas  is  rapidly  evacuated  by  peristalsis,  when  its  intermittent 
passage  through  the  pylorus  may  be  felt  and  heard. 

Inflation  should  not  be  used,  unless  valuable  information 
in  the  particular  case  is  likely  to  be  gained  by  it.  But  a  more 
important  contraindication  is  furnished  by  the  liability  to  do 
injury.  It  should  not  be  employed  in  ulcer  nor  in  advanced 
carcinoma,  nor  where  the  clinical  history  makes  it  likely  that 
perigastritis  and  peritoneal  adhesions  exist.  The  carbon- 
dioxid  method  should  not  be  used  when  flatulency  produces 
great  distress  or  gastric  spasm,  or  when  there  is  gastric  re- 
tention. Tiie  other  contraindications  are  those  against  the 
use  of  the  tube.  It  is  unnecessary  to  say  that  neither  method 
should  be  employed  during  the  period  of  physiological  ac- 
tivity of  the  stomach.  If  the  acid  and  soda  method  of  infla- 
tion be  selected,  it  is  a  good  plan  to  have  a  stomach-tube 
ready  for  the  removal  of  the  gas  whenever  (as  almost  never 
happens)  the  gaseous  distention  produces  much  discomfort. 

Inflation  gives  the  best  results  with  thin  abdominal  walls, 
when  the  limits  of  the  stomach  may  be  plainly  seen,  felt,  and 
marked  out  by  percussion.  It  may  reveal,  as  no  other  method 
does,  vertical  displacement,  total  descent,  and  enlargement  of 
the  stomach  ;  or  it  may  exclude  these  conditions.  The  tumors 
of  the  lesser  curvature  may  be  turned  back  out  of  reach, 
those  of  the  pylorus  may  be  revealed,  while  those  of  the 
greater  curvature  and  of  the  anterior  wall  may  become  less 
distinct  and  less  sharply  limited.  The  tumors  of  the  posterior 
wall  are  further  removed  from  physical  examination. 

The  inflation  is  useful  not  only  in  determining  the  loca- 
tion, size,  and  form  of  the  stomach,  but  also  the  presence  of 
adhesions  and  the  size  and  origin  of  tumors.  To  reveal  the 
capacity  of  the  stomach  and  to  determine  the  strength  of 
its  muscular  layer  the  method  is  worthless  clinically,  even 
though  the  quantity  of  air  used  be  measured,  inasmuch  as 
part  of  it  may  escape  through  the  pylorus  or  cardia  ;  and  the 
reflex  muscular  activity  and  the  degree  and  ease  of  disten- 
tion do  not  measure  the  retraction  power  of  the  stomach. 
Schreibcr,  Jaworski,  Kelling,  and  Ost  have  described  meth- 
ods for  estimating  the  cajjacity  of  the  stomach.  The  prin-  . 
ciple  embodied  in  all  these  methods  is  the  same,  but  different 
means  are  employed  for  measuring  the  quantity  of  air  that 
can  be  introduced  into  the  stomach  before  the  distention  be- 
comes |)ainful.  These  methods  are  not  sufficiently  accurate 
nor  simple  to  be  of  much  clinical  value.  The  information 
given  by  any  method  concerning  capacity  is  of  little  value. 


THE    PHYSICAL    SIGNS.  75 

6.  Auscultation. — Gastric  sounds  have  not  been  studied 
with  the  care  that  the  subject  deserves.  The  information 
obtained  by  the  sounds  produced  at  the  orifices  and  in  the 
body  of  the  stomach  may  aid  in  the  discovery  of  abnormal 
conditions.  These  auscultation  signs  are  the  deglutition 
sounds  heard  at  the  cardia ;  the  pyloric  and  perforation 
evacuation  sounds  ;  the  peristaltic,  cardiac,  aortic,  respiratory, 
and  fermentation  sounds  ;  succussion  and  percussion  splash- 
ing- 

The  deglutition  sounds  may  be  changed  in  the  diseases  of 

the  cardia,  but  not,  however,  by  diseases  of  the  cardia  only. 
The  esophagus  also  plays  an  important  part  in  their  produc- 
tion. But  apart  from  diseases  of  the  esophagus,  the  degluti- 
tion sounds  may  be  given  a  negative  diagnostic  value  in  that 
their  presence  and  their  normal  qualities  exclude  certain 
disorders  of  the  cardia. 

The  deglutition  noises  are  two  in  number:  The  first  fol- 
lows immediately  after  the  patient  swallows  the  mouthful 
of  water,  and  is  forcible,  spurting,  quick  ;  the  second  follows 
in  from  five  to  fifteen  seconds,  and  is  dull,  labored,  and 
bubbling.  When  both  these  signs  are  normal  we  may  give 
them  a  negative  meaning,  with  great  probability,  and  may 
exclude  organic  and  spasmodic  obstruction  of  the  cardia. 
Both  deglutition  sounds,  particularly  the  first,  may  be  absent 
at  times  in  health,  but  their  constant  absence  is  evidence  of 
the  complete,  or  almost  complete,  obstruction  of  the  esopha- 
gus or  of  the  cardia.  In  spasm  of  the  cardia  both  sounds 
are  often  delayed.  The  delay  and  prolongation  of  the  sec- 
ond sound  is  a  sign  of  stenosis  of  the  cardiac  orifice,  the  two 
sounds  being  often  separated  by  an  interval  of  about  one 
minute.  The  sounds  are  best  heard  to  the  left  of  the  ensi- 
form  process,  in  front;  or  on  a  level  with  and  to  the  left  of 
the  spinous  process  of  the  ninth  dorsal  vertebra,  behind.  It 
seems,  after  careful  study,  more  than  probable  that  the  two 
sounds  mark  the  noisy  beginning  and  ending  of  the  same 
process,  the  interval  between  them  being  occupied  by  the 
entrance  of  the  water  into  the  stomach.  The  test  should  be 
made  with  a  full  swallow  of  water. 

The  pyloric  evacuation  sound  is  of  a  quick,  spurting,  bub- 
bling, metallic  character.  This  auscultation  sign  may  become 
very  important  in  special  conditions,  and  is  of  very  much 
greater  diagnostic  value  than  the  cardiac  deglutition  sounds. 
The  pylorus  may  be  auscultated  during  digestion,  or  when 
the  stomach  should  be  empty,  or  after  the  patient  has  taken 
a  glass  of  water.     During  the  period  of  repose  of  the  normal 


76  DISEASES  OE  THE  STOMACH. 

Stomach  no  sound  is  heard  in  tlie  pylorus.  If  a  glass  of 
water  be  given,  the  sound,  recurring  at  intervals  of  about  one 
minute,  may  be  very  plainly  heard  with  the  stethoscope 
placed  over  the  p\'lorus.  The  pyloric  evacuation  sound  may 
be  utilized  to  locate  the  pylorus  when  it  can  not  be  felt,  and 
also  to  identify  it  when  displaced.  It  is  also  a  measure 
of  peristaltic  activity.  In  myasthenia,  the  beginning  of  peri- 
stalsis after  a  meal  is  delayed,  the  peristaltic  intervals  are 
long,  and  the  pyloric  evacuation  sound  may  be  heard  when 
the  stomach,  if  normal,  would  be  empty.  In  compensated 
obstruction,  the  peristalsis  is  often  quick  and  powerful,  and 
accompanied  by  a  regurgitation  sound,  which  is  different  in 
character  from  the  firm  pyloric  spurt.  Though  peristalsis  be 
active,  the  sound  is  absent  during  pyloric  spasm.  It  is  never 
heard  in  complete  obstruction  of  the  pylorus. 

In  perforation  of  the  stomach,  cases  have  been  reported  in 
which  the  intermittent  escape  of  the  contents  into  the  peri- 
oneal  cavity  could  be  heard.  This  auscultation  sign  is  rarely 
sought,  and  has  not  been  so  clearly  defined  as  to  be  employed 
in  diagnosis. 

The  fermentation  sounds  in  the  stomach  may  often  be  heard 
in  stagnation  and  retention,  with  active  formation  of  gas. 
They  are  very  fine  crackles,  like  the  bursting  of  numerous 
bubbles  in  a  partly  filled  vessel,  and  can  be  artificially  pro- 
duced by  the  administration,  separately,  of  a  little  tartaric  acid 
and  soda.  They  may  be  most  easily  found  if,  after  the  patient 
has  remained  perfectly  motionless  on  the  back,  breathing 
quietly  and  regularly  for  a  few  minutes,  the  stomach  be 
slightly  agitated  while  the  stethoscope  is  placed  over  it.  If 
these  sounds  are  heard  during  the  period  when  the  stomach 
should  be  empty,  they  denote  that  the  stagnation  or  reten- 
tion, as  the  case  may  be,  is  accompanied  by  gas-forming  fer- 
mentation. 

Sounds  are  also  produced  in  the  stomach  by  peristalsis. 
These  gentle,  flowing,  rushing,  bubbling  sounds  occur  nor- 
mally during  the  period  of  digestion,  and  are  usually  loudest 
near  the  pylorus.  If  heard  during  tiie  period  when  the  stom- 
ach should  be  empty,  they  denote  either  stagnation  or  reten- 
tion. 

In  abnormal  conditions,  the  heart  sounds  may  be  heard 
over  the  region  of  the  stomach,  and  may  possess  metallic, 
resonant  qualities.  This  physical  sign  may  be  due  to  disten- 
tion of  the  stomach  with  gas,  to  upward  displacement  of  the 
stomach,  to  pericardiac  adhesions,  or  to  subdiaphragmatic 
abscess.     It   denotes   an  abnormal  condition  of  the  heart,  or 


THE    PHYSICAL    SIGNS.  yj 

of  the  stomach,  or  of  their  relations;  and  when  it  is  constant, 
a  search  for  the  significance  should  be  made. 

The  respiratory  murmur  of  forced  breathing  may  sometimes 
be  heard  over  the  stomach  in  perigastritis,  in  pleurodia- 
phragmatic  adhesions,  in  peritonitis,  and  in  ascites.  The 
pulsations  of  the  aorta  may  rarely  produce  intragastric 
sounds,  and  an  aortic  bruit  may  be  transmitted  and  its  quali- 
ties modified  by  the  contents  of  the  stomach.  These  auscul- 
tation signs  are  of  no  value  in  the  diagnosis  of  the  diseases  of 
the  stomach. 

Intragastric  noises  are  very  frequent  and  important  aus- 
cultation signs.  For  diagnostic  purposes,  they  may  be  sepa- 
rated into  gurgling,  clapping,  and  splashing,  the  other  intra- 
gastric sounds  having  been  already  described. 

Gastric  gurgling  may  be  respiratory,  or  may  be  elicited 
by  the  physician  alternately  compressing  two  compartments 
of  the  stomach,  or  by  the  gliding  method  of  Glenard.  Its 
production  requires  the  presence  of  very  special  conditions — 
a  flabby  stomach  containing  gas,  or  gas  and  liquid,  separated 
by  a  constriction  or  by  compression  into  two  cavities,  the 
contents  of  one  of  which  are  forced  into  the  other.  A  certain 
relation  must  exist  between  the  properties  of  the  contents  of 
the  compressed  cavity,  the  size  of  the  communicating  canal, 
and  the  tension  of  the  receiving  cavity,  otherwise  gastric 
gurgling  can  not  occur. 

Respiratory  gurgling  is  more  frequent  in  women  than  in 
men.  The  corset  or  the  belt,  the  left  arm  laid  across  the 
abdomen  while  the  person  lies  on  the  back,  the  colon,  the 
enlarged  spleen,  the  enlarged  left  lobe  of  the  liver,  a  tumor, 
adhesions,  or  constricting  bands  deforming  the  stomach  and 
dividing  it  into  two  pouches,  may  induce  constriction  or 
compression.  In  the  majority  of  cases  the  stomach  is  dis- 
placed and  myasthenic.  The  compression  of  the  cavity  from 
which  the  contents  are  driven  is  made  directly  by  the  de- 
scending diaphragm,  or  indirectly  by  the  ascent  of  the  dia- 
phragm. A  double  respiratory  gurgle  is  not  rare.  The 
respiratory  gurgle  is  pathological,  and  indicates  myasthenia, 
displacement,  deformity,  or  abnormal  compression.  If  it 
occurs  at  a  period  when  the  stomach  should  be  empt)^ 
it  reveals  stagnation  or  retention  ;  for  the  non-functionat- 
ing stomach  should  retract  and  contain  no  fluid  and  little 
or  no  gas. 

Under  suitable  conditions,  gastric  gurgling  may  be  pro- 
duced by  the  gliding  method  of  Glenard.  The  stomach 
is  gently  compressed    against   the  vertebral  column  by  the 


78  DISEASEii  OF  THE  STOMACH. 

border  of  the  hand  transversely  placed  across  the  abdo- 
men— at  the  end  of  inspiration — in  such  a  manner  as  to 
shut  off  a  pouch  from  the  general  cavity  of  the  stomach. 
The  line  of  compression  is  moved  downward  during  ex- 
piration, and  the  gurgle  is  produced.  Glenard  regards  this 
as  one  of  the  signs  of  the  descent  of  the  pylorus,  and  claims 
that  the  intragastric  pressure  is  lower  than  normal,  and  that 
the  stomach  is  small,  the  gurgle  always  being  above  the 
umbilicus.  This  very  e.xact  meaning  the  sign  does  not 
possess,  for  it  may  be  produced  also  in  myasthenia,  in  the 
prolapsed  as  well  as  in  the  vertical  stomach,  when  the  bor- 
der of  the  stomach  is  below  the  umbilicus,  and  may  even 
be  produced  to  the  right  of  the  median  line,  when  the  lesser 
cul-de-sac  is  flabby  and  displaced  downward  to  the  right — it 
being  only  necessary  so  to  locate  and  shape  the  line  of  compres- 
sion as  to  shut  off  a  pouch  containing  gas.  or  gas  and  fluid.  By 
the  gliding  method,  the  lower  border  of  the  stomach  may 
sometimes  be  felt  to  slip  from  beneath  the  hand.  It  is  un- 
necessary to  state  that  this  gastric  palpation  sign  should  not 
be  confused  with  the  movable  gurgling  ribbon.  The  gliding 
gurgle  and  the  gliding  palpation  may  be  used  to  locate  the 
lower  limit  of  the  stomach,  when  the  very  particular  condi- 
tions for  the  realization  of  the  signs  are  present. 

Gastric  clapping  is  produced  by  bringing  the  walls  of  the 
stomach  separated  by  gas  into  contact  by  a  simple,  quick  de- 
pression of  the  epigastrium  in  the  median  line.  A  somewhat 
similar  sound  may  be  elicited  by  clapping  the  anterior  wall 
of  the  stomach  against  the  surface  of  the  liquid  from  which  it 
is  separated  by  a  layer  of  gas  :  but  in  this  condition  gastric 
splashing  may  also  be  heard.  As  the  word  implies,  it  differs 
in  its  qualities  from  gastric  splashing  which,  unlike  clapping,  can 
not  be  generated  when  the  patient  is  standing.  It  is  unneces- 
sary to  state  that  succussion  can  only  yield  splashing  sounds. 
Gastric  clapping,  engendered  during  the  period  of  physiologi- 
cal repose,  is  a  sign  which  suggests,  but  does  not  establish, 
myasthenia.  When  it  can  be  produced  below  the  umbilicus, 
the  clapping  denotes  that  the  stomach  is  either  enlarged  and 
mj'asthenic  or  is  displaced. 

Gastric  splashing  occurs  in  a  stomach  containing  gas  and 
fluid — it  matters  not  whether  the  wall  be  flaccid  or  rigid. 
The  sound  may  be  generated  in  many  ways — by  motion  of  the 
trunk,  by  the  rapid  movements  of  the  diaphragm,  by  the  con- 
traction and  relaxation  of  the  abdominal  muscles,  by  alternat- 
ing depression  at  two  points,  by  compression  at  one  point 
and  tapping  at  another,  or  by  three  or  four  rapid  depressions 


THE   PHYSICAL    SIGNS.  79 

over  the  stomach  (particularly  at  the  end  of  expiration)  with- 
out raising  the  fingers  from  the  abdominal  wall.  One  method 
may  succeed  when  the  others  fail  to  elicit  the  sound.  The 
patient  should  lie  fiat  on  the  back,  with  the  muscles  relaxed, 
and  the  stomach  should  not  be  distended.  Gastric  splashing 
may  occur  during  the  period  of  digestion.  The  stomach 
may  then  be  normal.  But  constant  splashing  during  the  di- 
gestion of  a  meal  should  excite  suspicion.  The  sign  may  be 
produced  when  the  stomach  should  be  empty,  and  is  then 
always  pathological,  and  reveals,  according  to  the  moment 
when  the  examination  is  made,  either  excessive  secretion  or 
stagnation  or  retention.  Splashing  may  be  absent  during  the 
period  of  physiological  rest,  and  be  elicited  by  none  of  the 
methods  employed,  even  at  the  end  of  expiration.  If  half  a 
glass  of  water  be  now  given,  and  the  sign  be  present,  suspi- 
cion should  be  excited.  After  an  interval  of  half  an  hour  if 
the  examination  is  again  positive,  there  is  myasthenia.  If, 
after  the  use  of  the  half-glass  of  water,  none  of  the  gastric 
noises  can  be  elicited,  the  motor  power  of  the  stomach  is 
normal.  The  area  over  which  the  splashing  can  be  produced 
is  also  useful  in  locating  the  stomach  and  in  detecting  its  dis- 
placement. But  we  must  first  be  sure  that  the  sound  is 
intragastric. 

Either  a  splashing  or  a  clapping  sound  may  be  produced  in 
the  colon,  containing  a  mixture  of  gas  and  fluid,  or  only  gas. 
Constipation,  so  frequent  in  myasthenia,  would  make  it  prob- 
able that  the  sound  is  intragastric.  Palpation  of  the  colon 
may  at  once  clear  up  the  difficulty,  for  it  is  narrow  and  rib- 
bon-like or  cord-like,  and  rarely  its  contents  may  be  solid. 
The  area  of  distribution  might  correspond  in  location  and 
somewhat  in  form  with  either  the  colon  or  the  stomach. 
The  sound  first  produced,  after  the  drinking  of  the  half- 
glass  of  water,  is  intragastric.  In  doubtful  cases,  the  empt)-- 
ing  of  the  stomach  by  the  tube  might  locate  the  noise,  but  it 
is  better  to  repeat  the  examination  on  the  following  day  if 
the  source  of  the  sounds  is  not  made  clear.  But  the  possi- 
bility of  the  colon  and  the  stomach  at  the  same  time  yielding 
clapping  or  splashing  sounds  should  not  be  forgotten. 

The  area  of  the  splashing,  which  should  be  marked  out  by 
using  gently  one  or  two  fingers  in  producing  the  rapid,  suc- 
cessive, vertical,  and  slight  depressions  in  order  to  localize  the 
effect,  may  reveal  the  size  and  the  location  of  the  stomach, 
and  may  thus  enable  us  to  discover  or  to  exclude  a  di.«;place- 
ment,  a  large  myasthenic,  or  an  obstructed  organ.  We  may 
proceed  in  either  of  two  ways.     The  splashing  is  most  easily 


So  DISEASES  OE  THE  STOMACJI. 

excited  and  most  constant  o\er  the  triangle  of  contact  of 
the  stomach  with  the  abdominal  wall,  bounded  by  the  me- 
dian line,  the  left  costal  border,  and  a  line  uniting  the  carti- 
lages of  the  ninth  rib.  The  cartilage  of  the  ninth  rib,  which 
is  one  of  the  landmarks  of  the  stomach,  may  be  readily  found 
by  passing  the  finger,  from  below,  along  the  costal  border. 
The  first  notch  is  between  the  very  movable  tenth  cartilage 
below  and  the  less  movable  ninth  cartilage  above.  Over  this 
area  the  gastric  splashing  will  be  found.  We  proceed  from 
this  area  downward  and  to  the  right,  and  unite  points  where 
the  splashing  disappears ;  or  proceed  from  below,  along 
parallel  vertical  lines,  and  from  the  right,  along  parallel  hori- 
zontal lines,  toward  the  region  of  the  stomach,  and  mark  and 
unite  the  points  where  the  splashing  begins.  The  lower 
limits  may  be  more  easily  marked,  when  the  patient's  shoul- 
ders are  slightly  raised,  and  the  physician  steadies  the  stomach 
by  gentle  pressure  over  the  pyloric  region.  To  find  the  right 
limit,  the  patient  may  be  turned  very  slightly  on  the  right 
side.  In  the  attempt  to  locate  the  stomach  by  direct  percus- 
sion splashing  it  often  happens  that  the  sound  is  not  produced 
immediately  beneath  the  fingeVs,  and  the  lower  boundary  of 
the  stomach  may  be  placed  too  high  or  too  low.  The  sound 
is  produced  where  the  gas  and  fluid  mix,  and  the  lower  part 
of  the  stomach  may  contain  only  fluid,  or  the  fluid  may  all 
gravitate  backward  into  the  greater  cul-de-sac,  and  leave  only 
gas  in  the  part  of  the  stomach  beneath  the  epigastrium  ;  or, 
again,  the  finger  agitation  may  be  transmitted  to  the  stomach 
through  the  medium  of  an  adjacent  organ.  The  tapping 
should  be  light,  and  the  result  controlled,  where  possible,  by 
the  gliding  method  of  Glenard.  To  avoid  the  error  due  to 
the  distribution  of  the  contents  of  the  stomach,  the  depres- 
sions with  the  fingers  should  be  made  near  the  line  of  the 
greater  curvature,  at  the  end  of  a  deep  inspiration,  and,  also, 
while  the  other  hand  of  the  physician,  which  is  laid  flat  on 
the  epigastrium,  gently  compresses  the  upper  part  of  the 
stomach.  It  is  a  useful  precaution  to  ascertain  whether  the 
boundary  of  splashing  is  changed  after  the  administration  of 
half  a  glass  of  water. 

The  constant  absence  of  gastric  .splashing  during  the 
period  when  the  stomach  would  be  normally  empty  ex- 
cludes myasthenia  with  certainty.  The  strong,  healthy 
stomach  does  not  splash  during  the  period  of  digestion,  or 
only  splashes  intermittently  as  the  stomach  momentarily  re- 
laxes. The  complete  absence  of  splashing  occurs  only  when 
the  stomach  is  verv  strong. 


THE   FUNCTIONAL    SIGNS.  8  I 

CHAPTER  111. 
THE  FUNCTIONAL  SIGNS. 

The  clinical  history  and  the  physical  examination  may  en- 
able us  to  form  a  correct  diagnosis  without  further  explora- 
tion. The  clinical  history  may  be  typical  and  the  physical 
signs  may  be  characteristic.  But  disease  does  not  develop  in 
grooves  and  yield  always  clear-cut  types.  We  may  even  go 
further  and  truthfully  say  that  in  the  large  majority  of  the 
cases  these  methods  leave  us  in  doubt.  How  often,  after  a 
most  painstaking  history  and  a  most  exhaustive  physical  ex- 
amination, we  must  be  content  with  a  probable  diagnosis,  or  a 
mere  guess  at  the  truth. 

This  additional  knowledge,  so  sorely  needed,  may  be  fur- 
nished in  part  by  the  functional  signs.  These  signs  possess 
both  positive  and  negative  value,  inasmuch  as  certain  persistent 
pathological  variations  may  reveal  a  particular  disease ;  and 
normal  functions,  or  a  particular  functional  anomaly,  may 
exclude  a  disease  suggested  by  the  previous  questioning  and 
the  physical  examination. 

But  the  functional  signs  are  even  more  valuable  in  treat- 
ment, and  have  the  great  advantage  of  being  direct  and  pre- 
cise. They  form  the  only  scientific  basis  of  the  dietetic  treat- 
ment, which  has  for  its  object  the  nourishment  of  the  body 
and  the  favoring  of  the  diseased  organ.  The  stomach  must 
work,  and,  this  being  the  case,  we  must  know  what  it  is 
capable  of  doing  before  we  ever  can  favor  it  in  its  duties  or 
avoid  overtaxing  it.  But  this  is  not  all.  The  functional 
signs  display  the  dynamic  variations,  be  they  hypersthenic  or 
asthenic,  and  consequently  suggest  and  control  the  physiolog- 
ical treatment.  Whether  our  remedies  be  foods  or  drugs,  or 
of  other  nature,  we  must  select  them  in  accordance  with  the 
commanding  physiological  indications — excitation  or  seda- 
tion. But  still  more ;  a  diagnosis  made  without  a  knowledge 
of  the  functional  signs  is  always  incomplete.  The  clinical 
history  and  the  physicj^l  signs,  in  a  small  number  of  the  cases 
of  stomach  troubles,  may  reveal  the  particular  disease,  such 
as  ulcer,  carcinoma,  gastroptosis,  gastritis,  or  one  of  the 
dynamic  affections.  The  anatomical  diagnosis,  however,  is 
insufficient.  To  treat  the  stomach  well,  its  functional  power 
must  be  known.     Without  such  knowledge  there  can  be  no 

intelligent  and  organized  effort  to  preserve,  restore,  and  com- 
6 


82  DISEASES  OF   THE   STOMACH. 

pensatc  its  functions.  And  we  hold  it  a  mistake  in  practice  to 
substitute  an  inference,  a  mere  guess,  for  the  definite  knowl- 
edge obtained  by  the  functional  exploration. 

The  functional  signs  are  also  helpful  guides  in  prognosis, 
revealing  how  serious  the  trouble  is  when  the  first  examina- 
tion is  made,  and  making  clear,  when  the  exploration  is  re- 
peated, the  gains  and  losses  and  the  general  tendency  of  the 
evolution  of  the  disease  of  the  stomach.  It  is  correct  practice 
to  make  a  functional  examination  whenever  this  can  be  done 
without  danger,  and  the  functional  signs  are  likely  to  prove 
valuable  in  diagnosis,  prognosis,  or  treatment. 

The  stomach  has  three  functions — general  and  special  se- 
cretion, the  churning  and  evacuating  movements,  and  absorp- 
tion. It  also  serves  as  a  reservoir,  the  filling  and  emptying 
of  which  is  roughly  self-regulating. 

The  contents  of  the  stomach,  obtained  during  the  period 
of  functional  activity  and  during  the  period  of  functional 
repose,  yield  functional,  bacteriological,  and  anatomical  signs. 
The  functional  signs  reveal  the  functional  power  and  activity 
of  the  stomach.  They  may  be  conveniently  treated  under 
the  following  divisions  :  (i)  Secretion  ;  (2)  the  motor  function  ; 
(3)  absorption  ;  (4)  digestive  work. 


I.  SECRETION. 

The  specific  secretions  of  the  stomach  are  three  in  number 
— the  acid,  and  two  ferments.  The  other  ferments  claimed 
to  exist  by  some  physiologists  possess  at  present  no  clinical 
importance.  The  general  secretion  of  the  stomach  is  the 
mucus.  The  secretions  of  the  stomach  are  formed  by  its 
glandular  lining  membrane,  which  displays  numerous  longi- 
tudinal folds.  Slightly  magnified,  the  lining  membrane  ap- 
pears reticulated,  the  little  pits  (several  millions  in  number) 
being  the  mouths  of  the  glands. 

The  surface  is  paved  with  a  single  layer  of  cylindrical 
epithelial  cells,  which  also  extend  to  a  variable  distance  into 
the  necks  of  the  special  secretion  glands.  Into  the  pyloric 
glands  they  extend  four  or  five  times  deeper  than  into  the 
glands  of  the  fundus.  The  mucous  glands  are  lined  through- 
out with  the  cylindrical  epithelium.  These  cells  are  long, 
thickly  packed,  and  sharply  limited,  except  at  their  concealed, 
deep  extremities.  The  basal  end  is  filled  with  a  finely  gran- 
ular protoplasm  up  to  near  the  central  part  where  the  nucleus 
lies.     From  the  nucleus  outward  to  the  free  or  surface  ex- 


THE   FUNCTIONAL    SIGNS. 


83 


tremity,  the  cells  contain  clear  mucus.  This  differentiation 
of  the  intracellular  contents  is  made  very  clear  by  staining. 
During  functional  activity  more  and  more  protoplasm  is 
transformed  into  mucin,  the  free  extremity  swells  and  bursts 
and  discharges  the  mucus  into  the  stomach.     The  cell  retains 


Fig.  4. — A,  Cross-section  ot  a  mucous  gland,  X  325.  B,  Cross-section  at  the  mouth  of 
a  peptic  gland,  X  325.  C,  Cross-section  at  the  neck  of  a  peptic  gland,  X  325:  i,  border 
cell ;  2,  chief  cells. 


I  1 

§  B 


Fig.  5. — A,  Surface  epithelium,  X  530.     B,  Border  cell,  X  530.     C.  Chief  cells  in  repose  (i) 
and  in  activity  (2),  X  530. 


Fig.  6. — Cross-sections  of  the  body  ot  a  peptic  gland  in  repose  (A)  and  in  activity  (B), 

X325- 


the  unconverted  protoplasm  and  the  nucleus,  and,  presenting 
a  goblet  shape,  begins  its  work  anew.  Mucus  secretion  is 
greatest  in  catarrhal  gastritis,  when  the  goblet  cells  are  also 
found  in  large  numbers.  The  mucus,  which  is  the  general 
secretion  of  the  stomach,  is  formed  by  the  cylindrical  cells. 


84 


DISEASES  OF   THE  STOMACH. 


The  special  secretion  glands  contain  two  kinds  of  cells — the 
chief  (adelomorphous)  and  the  border  (delomorphoiis)  cells. 
The  chief  cells  are  small,  cuboidal,  mononuclear,  badly  defined, 
and  filled  with  granular  protoplasm,  which  has  little  affinity  for 
the  anilin  dyes.  The  chief  cells  predominate  in  the  base  of 
the  gland,  are  less  numerous  in  the  fundus,  and  are  very  few 
in  number  near  the  neck  of  the  gland.  They  lie  next  to  the 
lumen  of  the  gland,  are  most  numerous  during  the  period  of 
functional  repose,  and  almost  disappear  at  the  height  of  secre- 
tory activity.  The  border  cells  are  large,  roundish,  well  de- 
fined, and  stain  deeply  with  the  anilin  dyes.  The  border- 
cells  predominate  near  the   neck   of  the  gland,  are   found  in 


Fig.  7.— Cross-section  of  normal  mucosa  through  the  necks  of  peptic  glands  one  hourafter 
the  test-breakfast,  X  240  (authors'  specimen). 


about  equal  number  as  the  chief  cells  in  the  fundus,  and 
only  here  and  there  along  the  base.  They  lie  near  the 
membrana  propria,  and  form  only  a  small  part  of  the  wall  of 
the  lumen.  The  border  cells  are  most  numerous  during  se- 
cretory activity,  and  are  very  few  in  number  after  long  fasting. 
In  the  glands  of  the  pyloric  region,  the  chief  cells  are  nu- 
merous, but  only  here  and  there  is  a  border  cell  found.  The 
border  cells  in  the  area  about  the  junction  of  the  pylorus 
and  the  body  of  the  stomach  differ  slightly  in  their  staining 
affinities  from  the  border  cells  found  in  other  parts  of  the 
stomach.  The  glands  also 'vary  in  their  size  and  form  in  the 
different  parts  of  the  stomach,  some  being  tubular  and  some 
branching,   some   long  and  others  short.     The   secretion   of 


THE   FUXCTIONAL    SIGNS.  85 

the  pyloric  region  is  less  acid,  but  contains  more  pepsin  than 
that  of  the  fundus  of  the  stomach.  But  it  is  more  than  prob- 
able that  the  chief  cells  do  not  form  the  ferments  exclusively, 
nor  do  the  border  cells  form  acid  alone.  The  border  cells 
undoubtedly  form  both  acid  and  ferments,  and  it  seems  very 
likely  that  the  border  cells  are  developed  from  the  chief  cells. 
A  study  of  development  and  of  cell  life,  and  the  data  of 
physiology  and  of  pathology,  make  this  theory  plausible. 

To  test  the  secretory  functions  of  the  stomach  we  require  : 
(i)  A  method  of  obtaining  the  contents  of  the  stomach  ;  (2) 
a  test-meal  to  excite  secretion  in  a  normal  manner,  and  (3) 
reagents  and  apparatus  necessary  for  the  analysis  of  the  re- 
moved contents. 

I.  Methods  of  Obtaining  the  Stomach=contents. — Many 
efforts  have  been  made  to  save  the  patient  the  disagreeable 
sensations  associated  with  the  use  of  the  stomach-tube.  Na- 
ture sometimes  imperfectly  does  the  work  for  us,  when  the 
patient  vomits  at  the  right  moment  during  the  digestive 
period,  or  in  the  early  morning  before  any  food  or  drink  has 
been  taken  into  the  stomach.  But  the  vomit  may  consist 
largely  of  the  secretions  accompanying  or  preceding  the  act, 
and  manifestly  can  not  be  taken  as  an  index  of  the  specific 
secretion  or  the  digestive  activity  conditioned  by  the  disease 
alone.  The  vomit  usually  consists  of  the  contents  of  the 
stomach  mixed  with  mucus,  with  bile,  with  pancreatic  juice, 
with  duodenal  secretion,  and  with  saliva.  Its  analysis  may 
give  some  valuable  information,  particularly  if  it  occurs  when 
the  stomach  should  be  empty,  or  at  a  certain  interval  after  a 
meal.  Continuous  secretion,  excessive  secretion,  the  power 
and  the  degree  of  secretion,  and  the  motor  activity,  may  be 
suggested  by  the  properties  of  the  vomit  when  the  vomiting 
occurs  under  certain  conditions.  But  the  information  thus 
obtained  must  be  complemented  and  confirmed  by  the  usual 
functional  tests.  In  no  case  can  the  examination  of  the 
vomit  render  unnecessary  the  test-breakfast,  the  test-dinner, 
the  test-supper,  or  the  morning  expression  and  lavage. 
The  examination  of  the  vomit  is  valuable,  but  the  act  can  not 
be  agreeably  produced  at  the  will  of  the  patient  or  of  the 
physician,  and  it  occurs  under  exceptional  circumstances. 

Some  of  the  very  laudable  endeavors  to  avoid  the  employ- 
ment of  the  tube  show  a  good  deal  of  ingenuity.  Einhorn  in 
i8go  proposed  as  an  easy  method  the  use  of  a  little  silver, 
olive-shaped  stomach-bucket  attached  to  a  strong  thread.  The 
thread  is  attached  to  an  internal  valve-like  lid,  which  closes 
the  mouth  when  the  thread  is  tight,  and  leaves   it   open  when 


86  DISEASES  OF   THE   STOMACH. 

the  thread  is  relaxed  by  the  bucket  reaching  the  gastric  con- 
tents. The  inventor,  however,  now  attaches  the  thread  to  a 
ring  on  the  inside  of  the  bucket,  and  claims  that  on  account 
of  the  bucket  being  full  when  withdrawn,  the  contents  are  not 
like!}'  to  become  mixed  with  other  secretions.  The  bucket  is 
carried  into  the  stomach  by  a  big  swallow,  remains  there 
a  while,  and  is  then  drawn  out  by  the  thread  and  pulled  over 
the  larynx  while  the  patient  makes  an  effort  to  swallow. 
The  small  amount  of  contents  is  tested  for  free  HCl  and  for 
ferments. 

Edinger  had  already  (1880-81)  proposed  a  similar  method, 
the  principle  of  which  is  as  old  as  Spallanzani.  Small  pieces 
of  sponge  are  freed  from  alkaline  carbonates  by  treatment 
with  hydrochloric  acid,  and  by  washing  with  distilled  water 
until  tlie  reaction  is  neutral.  The  dried  compressed  sponge, 
to  which  a  silk  thread  is  attached,  is  inclosed  in  a  gelatin  cap- 
sule, the  thread  being  drawn  through  a  perforation  in  the 
cover.  The  capsule  is  next  smeared  with  a  little  butter, 
swallowed,  and  washed  into  the  stomach  with  a  bite  of  bread 
and  some  water.  The  capsule  is  dissolved  in  the  stomach, 
the  sponge  is  uncovered,  and  after  fifteen  minutes  it  is  quite 
rapidh'  pulled  out,  saturated  with  the  gastric  contents.  The 
four  or  five  drops  thus  obtained  were  tested  for  free  HCl. 
The  capsule  may  be  swallowed,  according  to  our  object, 
while  the  stomach  is  empty,  or  at  a  certain  time  after  a 
meal. 

Spath  (1887)  recommended  a  little  bulb  of  elder  pith,  satu- 
rated with  a  solution  of  Congo-red,  to  be  swallowed,  and  thus 
dipped  into  the  contents,  and  withdrawn,  the  blue  coloration 
revealing  the  presence  of  free  acid. 

The  methods  of  Spath,  of  Edinger,  and  of  Einhorn  are 
hardly  more  pleasant  than  the  employment  of  the  stomach- 
tube.  Einhorn's  bucket  furnishes  enough  contents  for  a 
limited  qualitative  analysis. 

The  Sahli-Giinzburg  method  (1889-91)  was  extensively 
used.  About  three  grains  of  iodid  of  potash  are  tied  water- 
tight in  a  very  small,  thin  piece  of  rubber  tissue  by  means 
of  a  thread  of  fibrin.  Giinzburg  made  the  knot  with  the 
fibrin  thread,  while  Sahli  brought  the  two  ends  of  the  fibrin 
filament  together  and  tied  them  close  up  with  a  fine  thread. 
Giinzburg  administered  the  capsule  one  hour  after  the  test- 
breakfast;  Sahli  gave  it  with  the  te.st-breakfast.  The  trimmed 
packet  is  inclosed  in  a  gelatin  capsule,  swallowed  at  the 
desired  moment,  and  the  saliva  is  frequently  tested  for  iodin 
with   strongly   acidulated    starch    paper,   which    is    absorbed 


THE   FUNCTIONAL    SIGNS. 


87 


after  the  digestion  of  the  fibrin  string,  and  is  ehminated  by  the 
salivary  glands.  The  packet  may  be  opened  by  the  intestine 
instead  of  by  the  stomach,  or  in  the  stomach  by  organic 
acids,  or  even  by  chlorids  or  salines. 

Compared  with  the  use  of  the  tube,  none  of  these  ingeni- 
ous but  very  limited  methods  can  be  seriously  deemed  more 
than  an  elegant  amusement.  The  functional  tests  should  be 
thorough,  sufficient,  and  as  free  as   possible   from  error,  or 


Fig.  8. — The  extremities  and  openings  of  several  stomach-tubes  now  in  use:  a,  Ewald  ; 
b,  Riegel ;  c,  Hay  em  ;  d,  e.  Van  Valzah  and  Nisbet. 


they  should  be  omitted  altogether.  For  the  proper  explora- 
tion of  the  functions  of  the  stomach,  the  stomach-tube  is 
absolutely  necessary. 

The  stomach-tube  has  long  been  employed  in  therapeutics 
to  wash  out  the  stomach,  or  to  introduce  food  or  remedies. 
As  a  diagnostic  instrument,  it  is  used  to  detect  obstruction 
of  the  cardia,  to  locate  the  lower  border  of  the  stomach  by 
palpation   of  its   extremity  when    it  is   introduced,  to   inflate 


88  DISEASES  OF   THE   STOMACH. 

the  stonicich  with  air,  to  determine  the  duration  of  gastric 
digestion,  and  to  remove  tlie  contents  of  the  stomach  at  any 
desired  moment.  The  employment  of  the  stomach-tube  as 
an  instrument  of  diagnosis  and  research  lias  made  the  once 
obscure  subject  of  gastric  pathology  one  of  the  longest  and 
the  clearest  of  internal  medicine. 

Many  varieties  of  tubes  are  now  in  use.  A  good  one 
should  be  soft,  perfectly  smooth,  with  a  closed,  well-rounded, 
somewhat  conical  lower  end,  and  stiff  enough  to  allow  the 
slight  resistance  to  its  introduction  to  be  overcome  with- 
out its  curling  up.  It  should  possess  one  velvet-eye 
opening  of  the  same  size  as  the  caliber,  and  another  very 
small  one  with  similarly  depressed  or  rounded  edges.  The 
large  and  lower  opening  should  be  as  near  the  extremity  as 
possible,  and  the  caliber  of  the  tube  should  end  with  it.  The 
small  upper  opening,  on  a  level  with  and  opposite  the  upper 
border  of  the  large  opening,  diminishes  the  chances  of  the 
tube  becoming  obstructed  or  tearing  away  a  piece  of  the 
mucous  membrane  by  aspiration.  With  two  large  holes 
the  risk  of  obstruction  is  twice  as  great,  and  the  closing 
of  the  upper  hole  cuts  off  the  outflow.  The  two  large 
openings  weaken  the  tube,  and  the  stomach  can  be  emptied 
no  lower  than  the  higher  one  ;  but  the  mucous  membrane  is 
prevented  from  being  caught  by  suction  during  aspiration  or 
siphonage  and  is  thus  protected  against  injury. 

The  caliber  of  the  tube  should  be  as  large  as  it  is  possible 
to  make  it,  and  yet  retain  the  essential  elasticity  and  stiffness. 
The  length  should  be  75  to  90  cm.,  the  longer  ones 
being  useful  in  cases  where  the  greater  curvature  of  the 
stomach  is  low.  It  should  be  kept  as  scrupulously  clean 
as  a  catheter,  and  each  patient  with  syphilis,  tuberculosis,  or 
cancer,  should  have  one  for  his  exclusive  use. 

The  Indications  for  the  Use  of  the  Tube. — Experience  alone 
can  point  out  those  cases  in  which  an  exploration  of  the  func- 
tions of  the  stomach  is  likely  to  prove  of  most  value.  The 
tube  should  be  used  in  every  case  where  the  clinical  diag- 
nosis can  not  be  made  without  it,  and  where  no  contra- 
indication to  its  employment  exists.  Without  the  use  of 
the  tube  the  functional  power  of  the  stomach  can  only  be  in- 
ferred, and  the  inference  is  usually  far  from  the  truth.  An 
exploration  of  the  functions  of  the  stomach  is  never  useless 
and  is  rarely  unnecessary,  but  we  are  frequently  able  to  treat 
cases  successfully,  although  not  in  the  best  manner,  without  it. 

1.  The  tube  may  be  used  to  make  the  diagnosis. 

2.  The  tube  mav  be  used  to  confirm  the  diagnosis. 


THE   FUNCTIONAL    SIGNS.  89 

3.  The  tube  may  aid  in  reaching   a  diagnosis  by  exclusion. 

4.  The  tube  may  be  used  to  obtain  valuable  information  in 
prognosis  and  treatment,  and  to  determine  what  progress  has 
been  made. 

Contraindications  to  tlie  Use  of  the  Tube. — The  introduction 
of  the  tube  is  a  little  operation  which  may  need  to  be  aban- 
doned on  account  of  the  general  condition  of  the  patient,  or 
on  account  of  the  presence  of  some  particular  disease  render- 
ing it  dangerous  or  injurious.  The  contraindications  may 
be  multiplied  by  the  timidity  or  the  prejudices  of  the  phy- 
sician. The  contraindication  is  absolute  when  the  operation 
is  a  menace  to  life;  it  may  be  advisable  or  best  to  avoid  it 
under  other  exceptional  conditions.-  The  common  sense  and 
the  experience  of  each  physician  should  form  rules  for  his 
own  guidance. 

In  the  severe  acute  diseases  of  the  throat  and  the  stomach, 
in  general  peritonitis  and  in  perigastritis,  its  employnient  is 
contraindicated.  Advanced  soft  carcinoma  and  ulcer,  on 
account  of  the  danger  of  hemorrhage  or  perforation,  prohibit 
absolutely  the  introduction  of  the  tube,  as  do  also  a  sim- 
ilar condition  of  the  esophagus  and  the  existence  of  aneur- 
ysm of  the  aorta.  It  is  best  to  defer  the  operation  in  all  cases 
of  recent  hemorrhage.  Old  age,  adynamic  diseases,  uncom- 
pensated valvular  disease  of  the  heart,  degeneration  of  the 
heart  muscle,  arteriosclerosis  with  a  past  hemorrhage,  ad- 
vanced renal  disease,  cyanosis,  and  all  troubles  in  which  in- 
jury is  likely  to  result  from  a  slight  shock,  from  increase  of 
blood  pressure,  or  from  obstructed  respiration,  certainly  make 
it  advisable  to  avoid  the  use  of  the  tube,  except  in  very 
unusual  circumstances.  When  in  doubt,  it  is  best  to  give  the 
patient  the  benefit  of  it.  The  tube  should  rarely  be  intro- 
duced during  pregnancy,  and  never  if  there  is  a  history  of 
previous  abortion.  These  general  rules  may  sometimes  be 
violated  without  inflicting  injury,  and  the  refusal  of  the  patient 
to  permit  the  use  of  the  tube  may  render  a  search  for  contra- 
indications unnecessary. 

Introduction  of  tlie  Tube. — {(i)  The  Difficulties  of  Introduction. 
— The  first  difficulty  most  likely  to  be  met  with  is  an 
irritable  throat,  a  very  frequent  accompaniment  of  chronic 
gastritis.  If  the  patient  by  intelligent  co-operative  effort  and 
regular  breathing  can  not  overcome  the  choking,  the  pharynx 
should  be  anesthetized  with  cocain. 

An  obstruction  may  be  encountered  in  the  esophagus,  due 
to  stricture,  pocketing,  compression,  tumor,  swelling,  spasm, 
or  to  a  foreign  body. 


90  DISEASES  OF  THE  STOMACH. 

The  most  common  difficulties,  however,  are  faulty  manipu- 
lation on  the  part  of  the  physician,  and  the  resistance  of  the 
patient,  who  should  be  told  what  to  do.  A  little  knowledge 
may  dissipate  all  fear.  It  is  useless  to  try  to  force  a  soft  tube 
throu<^h  a  contracted  pharynx,  and  an  effort  to  do  so  is  very 
likely  to  result  in  the  curling  up  of  the  tube  in  the  throat,  or 
in  its  passage  into  the  larynx. 

(J))  The  Methods  of  Introduction. — The  finger  method  is  the 
older  one,  but  it  is  better  suited  to  the  introduction  of  bougies 
or  of  stiff  esophageal  sounds.  The  index-  and  the  middle 
fingers  of  the  left  hand  are  introduced  into  the  right  side  of 
the  mouth,  and  the  base  of  the  tongue  is  pressed  downward 
and  forward.  The  tube,  held  as  a  pen,  and  grasped  by  the 
right  hand  about  six  inches  from  its  extremity,  is  pushed 
along  the  left  index-finger  and  directed  slightly  to  the  right 
side  of  the  throat,  so  as  to  avoid  irritating  the  epiglottis. 
The  tube  is  next  pushed  on,  as  the  right  hand  is  elevated 
by  the  side  of  the  posterior  pillar  into  the  esophagus. 
The  operation  is  done  rapidly  and  gently.  As  soon  as  the 
tube  is  well  inserted  in  the  esophagus,  the  fingers  are  taken 
out  of  the  mouth  and  the  instrument  is  pushed  rapidly  into 
the  stomach,  the  patient  being  told  to  breathe  deeply.  It  is 
far  better  to  let  the  patient  direct  the  tube  into  the  esophagus 
by  swallowing.  The  fingers  commonly  excite  choking,  re- 
sistance, and  fear. 

The  technic  of  the  swallowing  method  is  very  simple: 
The  patient  sits  erect,  and  bends  the  head  sliglitly  forward, 
with  the  chin  a  little  elevated  ;  all  the  clothing  is  loose,  and 
both  hands  are  left  free  or  engaged  in  holding  the  receptacle 
for  the  contents.  The  tube,  wet  simply  in  warm  water,  is  held 
in  the  right  hand,  as  a  pen,  while  the  index-finger  and  the 
thumb  of  the  left  hand  protect  the  lips  and  steady  the  tube 
in  the  median  line.  The  tube  is  now  placed  on  the  tongue  as 
far  back  as  the  base,  the  patient  is  told  to  swallow,  and  as  the 
pomum  adami  rises,  the  progress  of  the  tube  is  aided  by  a 
gentle  push.  The  procedure  introduces  the  tube  into  the 
esophagus,  and  as  the  patient  breathes  quietly  the  instrument 
is  pushed  rapidly  on  into  the  stomacli.  The  sudden  yielding 
of  the  slight  resistance  offered  by  the  cardia  marks  the  en- 
trance of  the  tube  into  the  stomach. 

But  this  resistance  may  not  be  felt,  and  it  may  be  wise  to 
locate  the  cardia  before  beginning  the  introduction  of  the  tube. 
This  can  be  done  by  marking  on  the  tube  the  average  dis- 
tance of  the  cardia  from  the  incisor  teeth.  The  esophagus 
in    the   adult   is   about   25    cm.  long,  and   extends   from   the 


THE   FUNCTIONAL    SIGNS.  9 1 

lower  border  of  the  inferior  constrictor  muscle  of  the  phar- 
ynx behind  the  cricoid  cartilage  and  on  a  level  with  the  fifth 
cervical  vertebra  to  the  cardiac  orifice  of  the  stomach.  From 
its  beginning  it  turns  to  the  left  of  the  trachea,  and  passes 
behind  the  left  bronchus  on  its  way  to  the  abdominal  cavity 
through  the  esophageal  foramen,  ending  about  three  cm.  below 
the  diaphragm  in  the  cardiac  orifice  of  the  stomach.  The 
distance  of  the  cardia  from  the  incisor  teeth  is  about  40  cm. 
— 15  cm.  to  the  beginning  of  the  esophagus,  5  cm.  cervical, 
17  cm.  thoracic,  and  3  cm.  abdominal.  About  5  cm.  more 
should  be  added  so  as  to  bring  the  tube  well  within  the  cavity 
of  the  stomach ;  or  the  distance  from  the  incisor  teeth  to 
the  cardia  may  be  measured  by  placing  the  lower  end  of  the 
tube  over  the  tip  of  the  process  of  the  ninth  dorsal  vertebra, 
and  running  the  tube  along  the  spine  and  the  side  of  the 
neck  to  the  front  teeth.  To  express  the  contents,  the  open- 
ings of  the  tube  should  be  placed  just  within  the  cardia,  or 
below  the  level  of  the  contents.  To  remove  the  contents  by 
siphonage,  the  internal  end  of  the  tube  should  extend  to  the 
greater  curvature. 

After  the  tube  is  introduced,  it  should  always  be  held  in 
position,  in  order  to  prevent  its  accidental  complete  entrance 
into  the  stomach.  To  remove  the  tube,  first  draw  it  through 
the  cardia,  compress  it  tightly  between  the  thumb  and  index- 
finger  of  the  right  hand,  and  complete  the  removal  as  the 
thumb  and  index-finger  of  the  left  hand  catch  the  internal 
extremity. 

The  Removal  of  the  Stomach=contents. — The  contents  of  the 
stomach  may  be  obtained  in  three  ways:  (i)  by  suction  ;  (2) 
by  self-expression;  (3)  by  position  and  gravity. 

I.  Suction  is  the  oldest  method  (Jukes).  For  this  purpose 
the  pump  is  antiquated  and  the  modified  Politzer  bag  of 
Ewald  or  the  aspirator  of  Boas  (Fig.  9)  should  be  used. 

The  aspirator  of  Boas  consists  of  a  compressible  rubber 
bulb,  terminating  at  each  end  in  a  short  rubber  tube,  which 
may  be  compressed  by  the  fingers  or  closed  by  clamps.  One 
end  is  attached,  by  means  of  a  short  piece  of  glass  tubing,  to 
the  stomach-tube.  The  end  communicating  with  the  stomach- 
tube  is  clamped  and  the  air  driven  out  through  the  other 
end  by  compressing  the  bulb;  the  outer  end  is  next  clamped 
and  the  communication  with  the  stomach-tube  re-opened,  or 
the  end  may  be  fitted  with  a  valve.  The  contents  of  the 
stomach  are  drawn  into  the  bulb,  and  expelled  by  compres- 
sion, after  clamping  the  stomach-tube  end,  into  the  receiving- 
glass.     Strauss  recommends  a  very  excellent  apparatus.     It 


92 


DISEASES  OF  THE  STOMACH. 


consists  of  three  pieces  of  rubber  tiibinf^  fitted  with  clamps, 
attached  to  the  extremities  of  a  T-sliaped  piece  of  <;lass  tub- 
ing. One  of  the  tubes  is  attached  to  the  stomach-tube, 
another  to  a  funnel,  and  the  third  to  two  bulbs  like  those  of 
a  double  bulb  atomizer.  By  proper  manipulation  the  stomach 
can  be  washed  out,  inflated  with  air,  or  emptied.  Gross  in- 
serts a  glass  bulb  between  a  rubber  bulb  and  the  stomach- 
tube;  the  glass  bulb  receives  the  contents,  and  to  it  is  attached 
a  manometer. 

An  attempt  to  completely  em[)t)'*the  stomach   by  suction 
should  not  be  made,  but  only  enough  of  the  contents  should 


Fig.  9. — Boas'  aspirator. 


be  removed  to  serve  for  an  examination.  The  suction  should 
be  let  off,  and  some  water  allowed  to  flow  in,  before  the  re- 
moval of  the  tube.  This  method  should  be  used  whenever 
the  contents  of  a  degenerated  or  ulcerated  stomach  are  re- 
moved, or  when  the  patient  is  weak  or  has  advanced  disease 
of  the  lungs.  Expression  would  here  be  more  dangerous.  In 
cases,  also,  where  there  is  so  much  mucus  in  the  stomach  as 
to  prevent  expression,  aspiration  ma)'  be  employed. 

2.  Expression  is  quick,  and  requires  no  additional  instru- 
ment except  a  glass  to  receive  the  contents.  The  patient  has 
only  to  take  a  deep  inspiration,  hold  it,  and  contract  the  ab- 
dominal  muscles,  or  make  efforts  to  cough,  or  to  strain  as  at 


THE   FUNCTIONAL    SIGNS.  93 

Stool.  If  the  patient  can  not  or  will  not  co-operate,  the  tube 
may  be  moved  back  and  forth  through  the  cardia,  so  as  to 
excite  an  effort  to  vomit. 

3.  In  many  cases  the  contents  of  the  stomach  can  be  more 
easily  and  completely  removed  by  placing  the  patient  in  the 
horizontal  or  knee-elbow  position.  There  is  then  no  uphill 
curve  to  the  tube,  and  the  fluid  contents  are  easily  voided 
with  a  little  increase  of  abdominal  tension.  The  tube  should 
be  just  through  the  cardia,  and  held  in  the  mouth  so  as  to 
prevent  its  dragging  forward  on  the  larynx.  The  method  is 
very  valuable  in  completely  emptying  the  stomach,  and  is 
very  easy  and  efficient  when  the  patient  is  accustomed  to  the 
tube. 

Sometimes  no  contents  can  be  obtained.  The  failure  may 
be  due  to  several  causes  :  The  tube  may  be  obstructed  :  in 
this  case  it  can  sometimes  be  opened  by  forcing  a  little  air 
through  it.  But  the  obstruction  may  not  be  removable  by 
this  procedure,  and  the  tube  must  be  withdrawn,  and  again 
introduced  after  its  canal  is  opened.  The  tube  may  be  intro- 
duced too  far,  and  its  extremity  may  be  curled  up  above  the 
level  of  the  stomach-contents  :  This  fault  may  be  remedied  by 
withdrawing  the  tube  a  few  inches.  The  stomach-contents 
may  be  too  thick  or  too  coarse  for  removal,  or  the  stomach 
maybe  empty:  The  situation  maybe  cleared  up  by  intro- 
ducing a  little  water  and  then  withdrawing  and  analyzing  the 
fluid  obtained. 

2.  The  Test=meals. — The  exploration  of  the  functions  of 
the  stomach  should  be  made  under  conditions  as  nearly  alike 
as  possible  to  those  under  which  the  viscus 'ordinarily  does 
its  work.  Food  is  the  physiological  excitant  of  these  func- 
tions, and  a  test-meal  furnishes  a  natural,  simple,  practical, 
and  agreeable  excitant. 

Gastric  secretion  maybe  excited  by  electricity,  but  it  is  not 
practicable  to  use  this  agent  at  the  bedside  to  test  even  secre- 
tion. Thermal  and  chemical  excitants  once  met  with  some 
favor,  when  it  was  an  object  to  obtain  the  secretion  of  the 
stomach  unmixed  with  food.  Leube,  after  washing  out  the 
stomach,  introduced  50  c.c.  of  a  three  per  cent,  solution  of  soda, 
and  allowed  it  to  remain  in  the  stomach  twelve  minutes.  At 
the  expiration  of  this  period  50  c  c.  of  lukewarm  water  were 
introduced,  and  the  mixed  contents  were  withdrawn.  The 
reaction  of  the  mixture  should,  normally,  be  neutral.  If  the 
reaction  is  alkaline,  the  degree  of  alkalinity  represents  the 
degree  of  insufficiency  of  secretion.  Leube  also  introduced 
the  ice-water  method.     One  hundred  c.c.  of  ice-water  were 


94  DISEASES  OF  THE  STOMACH. 

introduced  through  the  tube,  and  at  the  end  of  ten  minutes 
300  c.c.  of  water  were  introduced,  and  the  wliole  contents 
immediately  witlidrawn.  The  liquid  was  tested  with  litmus 
and  tropasolin  for  acids,  and  for  ferments  by  artificial  diges- 
tion. Jaworski  improved  the  method  by  introducing  200  c.c. 
of  ice-cold  distilled  water  and  removing  it  without  dilution. 
The  method  is  no  longer  employed  by  the  great  clinician  who 
first  used  it. 

The  test-meals  proposed  are  very  numerous.  The  white-of- 
^gg  test-meal  was  recommended  by  Jaworski.  The  patient  is 
put  on  an  albuminous  diet  for  a  few  days  before  the  testing  is 
begun.  In  the  meantime,  the  state  of  the  stomach  in  the 
morning  before  breakfast  is  learned  by  aspiration  with  the  tube. 
If  the  exploration  is  negative  and  the  stomach  is  found  empty, 
100  to  300  c.c.  of  distilled  water  are  introduced  and  with- 
drawn.    The  fluid  withdrawn  is  saved  for  analysis. 

The  evolution  and  phenomena  of  digestion  are  ne.xt  studied, 
after  the  patient  has  taken  into  a  clean  and  empty  stomach 
the  white  of  one  or  two  hard-boiled  eggs,  with  100  c.c.  of 
distilled  water  at  the  temperature  of  the  room.  After  the 
patient  has  remained  quiet  for  forty-five  minutes,  he  is  allowed 
to  drink  lOO  c.c.  of  distilled  water,  and  five  minutes  later  the 
contents  are  aspirated  through  the  tube.  This  is  saved  for 
analysis.  The  stomach  is  further  washed  until  all  the  white 
of  Q.^'g  is  removed  and  the  undissolved  part  is  recovered  by 
filtration  and  compared  with  the  quantity  eaten.  On  a 
second  morning  the  test  is  repeated,  but  the  aspiration  is 
made  after  ninety  minutes.  The  normal  stomach  contains  no 
white  of  egg  after  the  expiration  of  seventy-five  minutes,  all 
having  been  digested  or  evacuated  undigested  into  the  duo- 
denum, except,  possibly,  a  few  pieces  caught  in  the  folds  of 
the  mucous  membrane.  The  maximum  of  digestive  activity 
is  attained  in  thirty  to  forty  minutes.  The  first  aspirations 
from  the  fasting  and  digesting  stomach  are  tested  for  reaction, 
free  HCl,  digestive  power,  mucus,  syntonin,  and  for  pep- 
tones, both  qualitatively  and  quantitatively.  Morphological 
elements  are  looked  for  with  the  microscope. 

The  method  of  Jaworski  is  an  excellent  one,  but  it  also  has 
its  disadvantages.  The  white  of  &^g  appeals  directly  to  the 
unique  secretory  work  of  the  stomach,  but  it  constitutes  a 
very  restricted  meal.  Klemperer  recommended  a  pint  of 
milk  and  two  small  rolls.  Bourget  recommends  20  gm.  of 
well-browned  dry  toast,  150  c.c.  of  weak  tea  without  sugar, 
and  a  teaspoonful  of  essence  of  peppermint.  But  the  test- 
breakfast  of  Ewald  and  Boas,  the  test-meal  of  Germain    See, 


THE  FUNCTIONAL    SIGNS.  95 

and  the  test-dinner  of  Riegel  have  best  stood  the  test  of 
time.     These  three  test-meals  meet  all  requirements. 

The  Test=breakfast  of  Ewald  and  Boas. — The  patient  is  given 
in  the  morning  on  an  empty  stomach,  one  roll  (about  70 
gm.)  and  350  c.c.  of  water  or  weak  tea  (about  i^  glasses). 
It  is  recommended  that  the  bread  be  taken  into  the  mouth 
dry,  be  thoroughly  masticated,  and,  after  insalivation,  washed 
down  with  the  water  or  tea.  Incomplete  mastication  delays 
the  digestion  of  the  crust,  and  the  particles  are  very  liable 
to  obstruct  the  tube.  One  hour  after  the  beginning  of  the 
breakfast  the  contents  are  removed. 

This  breakfast  contains  albumin,  starch,  sugar,  fat,  extrac- 
tive matter,  and  inorganic  salts,  is  rarely  repulsive,  easily  ex- 
pressed, and  suitable  for  chemical  analysis.  The  roll  weigh- 
ing 70  gm.  contains  about  5  gm.  of  proteids,  39  gm.  of 
carbohydrates,  i^  of  a  gm.  of  fat,  and  ^  of  a  gm.  of  ash. 
Normally,  at  the  end  of  an  hour  we  obtain  from  30  to  50 
c.c.  of  a  yellowish-tinged,  homogeneous  mixture,  filtering 
with  ease.  The  total  acidity  is  about  55,  the  acid  albumin 
acidity  about  45,  and  the  free  HCl  acidity  about  10.  These 
figures  represent  the  number  of  cubic  centimeters  of  a  deci- 
normal  solution  of  potash  or  soda  required  exactly  to  neu- 
tralize 100  c.c.  of  the  stomach-contents.  The  digestive  power 
of  the  filtrate  (Hammerschlag's  test)  is  about  90  per  cent. 
The  filtrate,  in  a  dilution  of  i  :  3000  with  ^V  normal  HCl  solu- 
tion, digests  albumin  after  remaming  in  the  thermostat  at  37° 
C.  for  twenty-four  hours.  Labferment  coagulates  milk  in  dilu- 
tion of  I  :  40,  and  labzymogen  in  dilution  of  i  :  160.  Free 
HCl  appears  in  thirty  minutes,  reaches  its  height  in  about 
one  hour,  and,  diminishing,  continues  to  the  end  of  gastric 
digestion.  Acetic  acid  and  ferrocyanid  of  potassium  give  a 
little  cloudiness  after  the  first  half-hour,  and  the  reaction  is 
demonstrable  to  the  end  of  digestion.  The  biuret  reaction 
(rose)  runs  the  same  course.  Fehling's  solution  is  reduced  dur- 
ing the  first  hour,  and  then  the  reaction  is  less  pronounced,  and 
disappears  entirely  in  one-half  to  three-quarters  of  an  hour 
before  the  end  of  digestion.  Lugol's  solution  gives  a  brown- 
ish-purple color  during  the  first  one  and  one-half  hours. 
The  contents  contain  no  blood,  a  small  quantity  of  mucus, 
possibly  a  little  bile  forced  through  the  pylorus  during  the 
expression,  and  a  small  number  of  micro-organisms.  No 
organic  acids  are  present,  unless  they  have  been  swallowed 
or  set  free  from  their  salts  by  the  HCl  of  the  gastric  juice. 
The  total  acidity  is  equal  to  the  HCl-albumin-acidity,  plus 
the    free    HCl,  plus    the    small  quantity  of  acid    phosphates 


96  DISEASES  OF  THE  STOMACH. 

which  are  usually  present.  The  stomach  is  empty  in  from 
two  to  two  and  one-half  hours  after  the  beginning  of  the  break- 
fast. The  following  table  displays  the  evolution  of  the  hy- 
drochloric acidity  during  the  normal  digestion  of  the  test- 
fa  reakfafst  : 


Total  acidity, 
HCl-all)umin, 
Free  IlCl,    . 


Thiriv 

MlNUTKS. 

Sixty 
Minutes. 

NiNHTV 

Minutes. 

20  to  30 
20  to  30 

0 

50  to   60 
40  to  50 
10  to   15 

30  to  40 

25    to   35 

5  to  10 

The  Test=meal  of  Germain  See. — The  test-meal  of  Germain 
See  consists  of  60  to  80  gm.  of  chopped  beef,  free  from  fat 
and  fibrous  tissue,  lOO  to  150  gm.  of  white  bread,  and  a 
glass  of  water.  It  is  best  to  give  definite  quantities,  and  we 
use  the  smaller  quantities  in  order  to  get  a  meal  which  de- 
mands more  work  of  the  stomach  than  does  the  test-break- 
fast and  much  less  than  does  the  test-dinner.  This  meal 
contains  about  20  gm.  of  proteids,  i^/^  gm.  of  fat,  56  gm. 
of  carbohydrates,  and  one  gm.  of  ash.  The  contents  are 
removed  two  hours  after  the  beginning  of  the  meal,  which 
should  not  be  eaten  rapidly. 

After  the  test-meal  of  Germain  See,  about  40  to  60  c.c.  of 
grayish-yellow  contents  are  obtained  at  the  end  of  two  hours. 
The  total  acidity  ranges  between  50  and  70,  the  free  HCl 
between  10  and  20,  and  the  HCl-albumin  between  40  and  50. 
With  Hammerschlag's  test  the  digestive  power  of  the  filtrate 
is  about  90  per  cent.  In  dilution  of  the  filtrate  (1  :  3000)  with 
4^  normal  HCl  solution,  albumin  is  digested  after  standing 
twenty- four  hours  in  the  thermostat  at  37°  C.  ;  labferment  is 
active  in  dilution  of  i  :  40.  and  labzymogen  in  dilution  of  i  :  160. 
Lugol's  solution  gives  a  brownish-violet  coloration.  Acetic 
acid  and  ferrocyanid  of  potash  produce  a  light  cloud.  Feh- 
ling's  test  reveals  a  moderate  quantity  of  sugar.  Very  few 
muscular  fibers  and  starch  granules  are  discoverable.  Free 
HCl  first  appears  in  one  and  one-fourth  to  one  and  one-half 
hours,  and  is  present  in  a  mere  trace  near  the  termination 
of  gastric  digestion.  The  biuret  reaction  is  positive  (rose- 
colored)  between  the  first  and  third  hours,  and  then  disap- 
pears. During  the  same  period  acetic  acid  and  ferrocyanid 
of  potash  produce  cloudiness.  Both  these  tests  are  negative 
during  the  last  fourth  of  digestion.  Fehling's  solution  is 
negative  during  the  last  half-hour  of  digestion.  The  stomach 
is  empty  in  three  and  one-half  hours  after  the  beginning  of 
the  meal.  The  following  table  di.splays  the  acidity  at  the 
end  of  each  hour  : 


THE   FUNCTIONAL    SJGNS.  97 

Onk  Hour.  Two  Hours.  Three  Hours. 

Total  acidity, 30  to  40  50  to  70  30  to  40 

HCl-albumin, 30  to  40  40  to  50  25  to  35 

P>ee  HCl, o  10  to  20  o  to  10 

The  Test=dinner  of  Riegel. — The  test-dinner  of  Riegel  con- 
sists of  a  plate  of  beef  soup,  150  to  200  gni.  of  beefsteak, 
50  gm.  of  puree  of  potatoes,  and  a  small  roll.  For  uniformity 
and  accuracy,  we  prescribe  300  c.c.  of  clear  beef  broth,  150 
gm.*  of  beefsteak  (fillet),  50  gm.  of  mashed  potatoes,  and 
35  gm.  of  white  bread.  This  meal  contains  about  36  gm. 
of  proteids,  3.5  gm.  of  fat,  30  gm.  of  carbohydrates,  and 
5  gm.  of  ash.  The  food  should  be  thoroughly  masticated, 
and  the  tough,  fibrous  pieces  of  the  steak  should  be  removed. 
The  contents  are  obtained  either  three  or  four  hours  after 
the  beginning  of  the  meal. 

The  quantity  of  contents  obtainable  ranges  from  40  to  70 
or  80  c.c.  The  total  acidity  varies  between  60  and  80, 
the  HCl-albumin  between  50  and  60,  and  the  free  HCl 
between  10  and  20.  Free  HCl  first  appears  in  about  two 
and  one-half  hours,  continues  about  two  hours,  and  disap- 
pears about  twenty  minutes  before  the  stomach  becomes  empty. 
The  biuret  reaction  (rose)  and  the  cloudiness  with  acetic  acid 
and  ferrocyanid  of  potassium  begin  near  the  end  of  the 
first  hour,  and  disappear  during  the  last  fourth  of  the  period 
of  gastric  digestion.  Very  few  striated  muscular  fibers  can 
be  found.  The  stomach  should  be  empty  at  the  expiration 
of  five  hours  from  the  beginning  of  the  meal.  The  ferments 
and  the  starch  products  are  present  in  the  same  strength  as 
in  the  test-meal  of  Germain  See.  The  following  table  makes 
clear  the  evolution  of  hydrochloric  acidity  : 

Two  Hours.  Three  Hours.  Four  Hours. 

Total  acidity, 40  to  50  45  to  70  60  to  80 

HCl-albumin, 40  to  50  45  to  60  50  to  60 

PVee  HCl, o  o  to  5  10  to  20 

The  test-breakfast,  the  test-meal,  and  the  test-dinner  reveal, 
accurately  and  fully,  the  secretory  activity  and  the  digestive 
work  of  the  stomach.  They  also  afford  a  rough  estimate  of 
its  motor  activity.  But  each  one  of  the  tests  has  its  advan- 
tages and  disadvantages.  The  test-breakfast  requires  only 
one  hour's  delay,  and,  furnishing  the  stomach  a  light  task, 
displays  the  secretory  activity  of  the  stomach  in  an  ideal 
manner.  The  chemical  analysis  of  the  contents  after  the  test- 
breakfast  is  easy.  But  it  does  not  fully  test  the  digestive 
power  of  the  stomach,  and  the  demands  made  on  the  stomach 
7 


98  DISEASES  OF  THE  STOMACH. 

are  much  less  than  those  of  the  usual  daily  meals.  To  test 
the  functional  sufficiency  of  the  stomach,  the  test-meal  of  See 
or  the  test-dinner  of  Riegel  is  necessary.  Indeed,  it  is  wise 
to  use  two  or  three  of  these  tests  in  order  to  avoid  errors,  and 
we  employ  them,  in  the  study  of  our  cases,  in  the  order  of 
the  increasing  demands  which  are  made  by  them  on  the  func- 
tions of  the  stomach.  The  information  obtained  in  this  man- 
ner suggests  to  the  experienced  clinician  what  further  tests 
are  advisable,  and  whether  it  is  necessary  to  search  for  a 
disorder  in  the  normal  evolution  of  digestion. 


I,   THE  HYDROCHLORIC  ACID. 

Before  proceeding  to  study  the  gastric  contents,  a  very 
important  physiological  and  practical  question  must  be  an- 
swered— viz..  Is  hydrochloric  acid  formed  by  the  cell  and 
given  out  in  a  free  state? 

All  authors  do  not  give  the  same  answer  to  this  question. 
Some  maintain  that  it  is  secreted  in  organic  combination  with 
leucin  or  pepsin.  Others  believe  that  the  hydrochloric  acid 
is  formed  by  lactic  acid  out  of  the  chlorids.  These  theories 
may  be  dismissed  without  further  consideration. 

Recently  another  theory  has  been  advocated,  which  main- 
tains that  the  free  hydrochloric  acid  found  in  the  gastric  con- 
tents is  a  by-product  of  digestion.  The  chlorids,  according 
to  this  theory,  are  the  physiologically  active  constituents  of 
the  secretion,  these  being  formed  in  the  cells  and  given  out 
by  them  chiefly  as  the  chlorid  of  sodium.  Working  in 
unison  with  the  pepsin  they  combine  with  the  proteids, 
and  in  so  doing  may  form  free  hydrochloric  acid.  According 
to  this  theory  of  Hayem,  the  free  hydrochloric  acid  in  the 
contents  is  not  a  cellular  but  a  chemical  and  digestive  by- 
product.    This  view  we  can  not  accept. 

The  almost  universally  accepted  theory — and  in  our  opinion 
the  true  one — claims  that  the  hydrochloric  acid  is  formed  and 
given  out  in  a  free  state  by  the  border  cells.  This  secreted 
hydrochloric  acid  unites  with  the  mucus,  the  exfoliated  cells, 
the  saliva  found  in  the  stomach,  and  the  inorganic  car- 
bonates, etc.,  of  the  food  and  saliva;  and  this  part,  for  the 
digestion  of  the  food,  is  lost;  another  part  unites  with  the 
proteids  of  tiie  food  and  converts  them  into  acid  compounds, 
which,  with  the  aid  of  pepsin,  are  built  up  into  albumoses 
and  peptones.  After  the  affinities  of  the  proteids  are  satis- 
fied, the  secreted  lu'drochloric  acid  remains  free.  The  hydro- 
chloric acid,  then,  is  secreted  free,  and  remains  free  only  after 


THE  FUNCTIONAL   SIGNS.  99 

it  is  in  excess.  This  excess  is  limited  by  the  normal  stomach, 
and  when  this  limit  is  exceeded  or  not  reached  within  the 
proper  time  for  the  particular  test-meal,  the  acid  secretion  is 
abnormal. 

Is  it  possible  to  estimate  the  quantity  of  HCl  secreted  ? 
If  it  be  remembered  that  this  secreted  acid  combines  almost 
immediately  with  inorganic  bases,  with  organic  bases,  and 
loosely  with  proteids  ;  that  the  stomach  discharges  its 
contents  into  the  duodenum  intermittently  throughout  the 
period  of  digestion,  forms  a  variable  quantity  of  mucus, 
exfoliates  a  variable  number  of  cells,  has  received  a  variable 
amount  of  bases  capable  of  being  drawn  away  from  their 
union  by  this  strong  nascent  mineral  acid  ;  that  the  stomach 
also  probably  absorbs  sufficiently  to  vitiate  the  results — it 
will  be  seen  that  the  estimation  of  the  total  amount  of  HCl 
secreted  is  surrounded  by  many  difficulties.  Moreover,  the 
quantity  of  saliva  secreted  in  twenty-four  hours  varies  from 
200  to  2000  gm.;  this  is  all  swallowed  and  enters  the  stom- 
ach. The  saliva  contains  inorganic  salts  in  the  proportion 
of  2.24  to  1000,  nearly  all  of  which  are  composed  of  the 
chlorids  and  carbonates  in  the  proportion  of  about  four 
parts  of  the  former  to  one  of  the  latter.  The  gastric  secre- 
tion also  contains  0.2  per  cent,  of  chlorids,  and  a  variable 
quantity  is  introduced  with  the  test-meals.  Of  the  inorganic 
chlorids  found  in  the  gastric  contents  after  a  test-meal,  a 
variable  part  is  formed  of  combinations  with  the  secreted 
HCl  and  a  variable  part  comes  from  other  sources.  It  is 
not  practicable  to  estimate  the  total  quantity  of  HCl  secreted 
during  the  digestion  of  a  meal,  but  it  is  possible  to  estimate 
the  total  quantity  found  at  a  particular '  moment  in  the 
stomach  which  is  physiologically  active,  and,  knowing  the 
total  acid-combining  power  of  the  proteids  in  the  particular 
test-meal,  to  estimate  roughly  the  total  quantity  of  the  se- 
creted HCl  which  has  been  used  in  the  digestive  transforma- 
tion of  the  food. 

The  secreted  HCl  in  inorganic  combination  is  lost  to  gastric 
digestion,  but  it  protects  and  influences  intestinal  digestion. 
The  union  of  the  acid  with  these  substances  is  strong,  and  all 
these  affinities  are  satisfied  before  the  HCl  combines  loosely 
with  the  proteids,  before  its  digestive  work  begins,  before  it 
remains  free.  Consequently,  the  HCl  which  combines  with 
the  proteids  and  that  which  remains  free  together  roughly 
represent  the  activity  of  acid  secretion.  The  albumin- 
combined  HCl  represents  the  actual  digestive  work.  We 
know  that  the  combined  and  unused  HCl  should  be  found  in 


lOO  DISEASES  OF  THE  STOMACH. 

certain  quantities  in  the  normal  stomach  in  the  very  par- 
ticular conditions  in  which  the  test  is  made.  We  therefore 
conclude  that  the  quantity  of  HCl  loosely  combined  with 
albumin,  together  with  the  quantity  remaining  free  in  the 
contents  withdrawn  at  the  end  of  a  particular  time  after  the 
eating  of  a  particular  meal,  is  a  practical  and  clinical  meas- 
ure of  the  secretory  activity  of  the  peptic  glands,  and  of  the 
digestive  work  of  the  acid  of  the  stomach. 

The  variations  from  this  clinical  standard  can  not  be  attri- 
buted exclusively  to  disease  of  the  border  or  chief  cells, 
which  may  or  may  not  be  normal.  The  healthy  stomach 
possesses  what  may  be  designated  as  its  acid  sense,  by  which 
the  hydrochloric  activity  is  held  fast  to  a  line  marking  the 
normal  evolution  of  acid  secretion  in  keeping  with  the  physi- 
ological action  of  the  contents.  This  special  sense  may  be 
disordered  ;  the  nerve-centers  concerned  with  the  secretion 
may  generate,  and  receive  or  send  out  morbid  impressions  ; 
the  circulation  may  not  be  good;  the  blood  may  be  impure  or 
poor ;  the  border  cells  themselves  may  be  diseased — and  one  or 
all  of  these  conditions  may  be  expressed  by  the  hydrochloric 
acidity.  The  acid  signs  are  of  great  value  in  detecting  an 
anomalv  ;  but  only  with  the  greatest  circumspection  should 
they  be  made  the  revealing  signs  of  a  particular  disease. 

To  estimate  the  hydrochloric  acidity  of  the  stomach- 
contents,  removed  either  during  fasting  or  during  the  diges- 
tion of  a  test-meal,  is  not  very  difficult.  The  details  of  the 
methods  can  be  mastered  by  study  and  practice.  No  very 
great  skill  is  required ;  neither  is  it  necessary  nor  expected 
that  the  clinician  should  be  an  expert  chemist.  But  if  it 
be  necessary  to  appeal  to  chemistry,  the  analysis  should  be 
exact  and  possess  a  precise  meaning. 

Some  of  the  many  methods  proposed  for  the  chemical  ex- 
amination of  the  gastric  contents  are  fit  only  for  the  laboratory. 
Their  finer  distinctions  and  greater  exactness  make  them 
preferable  in  scientific  research.  But  a  clinical  method  must 
be  simple  and  short ;  otherwise  the  demand  upon  the  skill 
and  the  time  of  the  practitioner  will  prevent  its  general  use, 
and  will  deprive  it  of  practical  value.  Any  long  and  compli- 
cated method  will  fall  into  disuse,  or  will,  at  best,  be  gener- 
ally deemed  a  mere  whim,  peculiar  to  a  few  doctors.  A 
description  of  the  more  complete  and  exact  methods  should 
find  a  place  in  a  special  work  of  this  kind.  The  useless  or 
erroneous  methods  require  no  mention.  The  simple  clinical 
methods  which  require  little  time  or  skill  will  usually  be 
found  sufficiently  exact  and  complete. 


THE   FUNCTIONAL    SIGNS.  lOI 

We  have  seen  that  the  hydrochloric  acid  secreted  by  the 
cells  of  the  glandular  lining  membrane  of  the  stomach  may 
be  found  in  four  states  in  the  contents  of  the  digesting 
stomach  : 

I.  Free,  when   secreted   in   excess   of  the  affinities  of  the 
organic  and  inorganic  matter  found  in  the  stomach. 
■  2.  Combined    with   the    proteids — a    loose,    acid-reacting, 
digestive  combination. 

3.  Combined  with  organic  bases. 

4.  Combined  with  inorganic  bases,  forming  chlorids. 
These  inorganic  chlorids  subtract  from  the  acidity  due  to 
secretion  just  so  much  as  the  chlorin  contained  in  them  repre- 
sents. The  inorganic  chlorin,  drawn  from  the  hydrochloric 
acid  secreted,  escapes  estimation,  and  is  lost  to  digestion. 

The  general  acidity  of  the  contents  of  the  digesting  stom- 
ach is  not  fully  represented  by  the  acidity  due  to  the  hydro- 
chloric acid,  which  is  free  and  combined  with  albumin.  Other 
factors  enter  and  make  it  more  complex.  The  general 
acidity  may  be  due  to — 

1.  Free  and  albumin-combined  hydrochloric  acid, 

2.  Free  organic  acids,  which  may  also  be  in  acid-reacting 
combination  with  proteids,  provided  no  free  and  stronger  acid 
is  present. 

3.  Acid  inorganic  salts,  chiefly  the  acid  phosphates. 

The  last  two  factors  of  general  acidity  are  introduced  into 
the  stomach  or  are  formed  there  without  the  aid  of  the 
specific  secretion.  The  organic  acids  are  chiefly  the  products 
of  micro-organisms  in  the  stomach,  and  will  be  carefully 
studied  with  the  bacteriological  signs.  The  functional  diag- 
nosis is  concerned  only  with  the  first  of  these  factors — the 
hydrochloric  acidity.  We  will  now  describe  how  the  free 
and  albumin-combined  hydrochloric  acid  in  the  mixture  repre- 
sented by  the  gastric  contents  can  be  detected  and  estimated. 
The  analysis  is  qualitative  and  quantitative. 

Qualitative  Tests. — The  qualitative  analysis,  which  often 
suffices  for  practical  purposes,  is  made  v/ith  color-reagents. 

The  gastric  contents  may  be  alkaline,  neutral,  or  acid.  If 
they  are  neutral  or  alkaline,  further  testing  for  hydrochloric 
acid  would  naturally  be  useless.  Consequently,  as  a  first 
qualitative  test  we  use  a  reagent  sensitive  to  all  free  acids, 
organic  acid  combinations,  and  acid  salts.  The  best  reagent 
of  this  kind  is  a  good  quality  of  litmus.  The  red  litmus 
paper  is  rarely  required  in  this  analysis,  as  an  alkaline  re- 
action of  the  contents  of  the  digesting  stomach  is  exceed- 
ingly rare.     The  blue  litmus  paper  is  so  sensitive  that  a  neg- 


I02  DISEASES  OF  THE  STOMACH. 

ative  result  is  at  once  final.  A  good  quality  gives  a  plain 
reaction  with  0.006  per  cent.  h\-drocliloric  acid,  0.0 1  per  cent, 
lactic  acid,  and  0.02  per  cent,  butyric  acid.  This  blue  dye, 
united  with  an  alkali,  is  soluble  in  water,  and  is  sensitive  to 
the  hydrochloric  acid  combined  with  albumin,  this  mineral 
acid  having  a  stronger  affinity  for  the  alkaline  base  of  the  dye 
than  for  albumin.  The  blue  litmus  is  consequently  reddened 
by  all  the  factors  of  general  acidity. 

The  second  acid  qualitative  test  is  made  with  Congo-red. 
This  is  a  red  dye,  soluble  in  water,  and  is  colored  blue  by  all 
free  acids.  It  is  three  or  four  times  more  sensitive  to  free 
hydrochloric  acid  than  to  the  free  organic  acids  of  the  gastric 
contents.  The  intensity  of  the  blue  coloration  increases  with 
the  percentage  of  free  acid,  and  organic  acids  produce  a 
muddy  grayish-blue  or  purple,  in  contradistinction  to  the 
pure  blue  of  the  mineral  acid.  But  even  a  very  extended 
e.xperience  should  not  permit  these  slight  distinctions  to  be 
valued  as  more  than  suggestions.  The  hydrochloric  acid  and 
other  acids  combined  with  albumin  or  organic  bases,  do  not 
alter  the  color  of  Congo-red.  Acid  phosphates,  in  very  con- 
centrated solution,  produce  a  brownish  coloration  ;  but  in  such 
quantities  as  are  found  in  the  stomach  after  a  test-meal,  pro- 
duce no  change  of  color.  Consequently,  the  Congo-red  is 
turned  blue  by  the  free  hydrochloric  and  the  free  organic 
acids.  The  acid  salts  and  the  acid  organic  combinations  are 
without  influence.  A  positive  reaction  means  the  presence  of 
a  free  acid.  Congo-red  may  be  used  in  aqueous  solution  or  in 
the  more  convenient  form  of  paper.  The  latter  reacts  plainly 
with  0.0 1  per  cent,  free  hydrochloric  acid  and  with  three 
times  the  quantity  of  lactic  acid.  The  solution  is  about  ten 
times  more  sensitive  than  the  paper,  which  is  made  by  satur- 
ating fine  filter  paper  with  an  aqueous  solution  of  Congo-red. 
After  it  is  dry,  the  paper  is  cut  into  narrow  strips  of  convenient 
length.  The  test  may  be  made  with  the  solution  by  spread- 
ing a  few  drops  over  a  white  ground, — as  in  a  watch-glass,  on  a 
piece  of  white  paper,  or  in  a  porcelain  crucible, — and  allowing 
a  drop  of  the  gastric  contents  to  flow  over  it  from  the  edge; 
the  area  of  contact  becomes  blue.  Or  the  paper  may  be  dipped 
into  the  mixed  contents,  after  the  ordinary  manner  of  using 
test-papers. 

The  third  qualitative  test,  in  case  the  Congo-red  gives  a 
positive  result,  is  for  free  hydrochloric  acid.  The  surest  and 
most  sensitive  reagents  for  this  purpose  are  those  of  Giinz- 
burcf  and  Boas. 


THE   FUNCTIONAL    SIGNS.  IO3 

The  reagent  of  Giinzburg  is  an  alcoholic  solution  of  phloro- 
glucin  and  vanillin  : 

Phloroglucin, 2  gm. 

Vanillin, I   gm. 

Alcohol  (absolute), 30  gm. 

This  reagent  is  uninfluenced  by  all  acid  salts  and  combina- 
tions and  by  free  organic  acids.  As  hydrochloric  is  the  only 
free  mineral  acid  present  in  the  gastric  contents,  unless  other 
mineral  acids  have  been  swallowed,  a  positive  reaction  with 
phloroglucin-vanillin  is  proof  of  the  presence  of  free  hydro- 
chloric acid.  This  regeant  is  also  very  sensitive.  With  a 
solution  of  I  :  10,000  the  very  fine  crystals  appear,  while  a 
solution  of  I  :  20,000  gives  a  red  coloration.  If  there  be 
much  organic  matter  in  the  contents,  the  red  is  mixed  with 
the  pasty,  dry,  yellowish  residue.  The  test  is  best  made  by 
placing  three  or  four  drops  of  the  reagent  in  a  porcelain 
crucible,  and  spreading  it  by  causing  it  to  flow  in  different 
directions  over  the  surface.  A  like  quantity  of  the  filtered 
gastric  contents  to  be  tested  is  now  added,  and  spread  over  the 
same  area.  With  a  small  flame  the  crucible  is  slowly  warmed, 
never  allowing  it  to  become  too  hot  to  be  comfortably  borne 
on  the  back  of  the  hand.  After  several  seconds  a  clear  red 
coloration  appears,  or  the  fine,  bright-red  crystals  may  be 
seen  if  free  hydrochloric  acid  be  present.  The  phloroglucin- 
vanillin  paper,  recommended  by  some  writers,  we  do  not  em- 
ploy. A  few  drops  of  the  gastric  contents  are  placed  on 
the  paper,  which  may  be  more  rapidly  heated  in  the  crucible 
than  with  the  solution  test. 

The  following  solution  of  Boas'  is  used  in  the  same  manner 
as  the  Giinzburg  reagent: 

Resorcin  (resublimed), 5  gm. 

White  sugar,   .    .        3  gm. 

Alcohol  (95  per  cent.), IC)0  gm. 

The  coloration  is  a  bright  rose-red.  This  reaction  of  the 
gastric  contents  is  characteristic  of  free  hydrochloric  acid.  It 
is  very  sensitive,  and  may  be  even  clearer  than  the  Giinzburg 
reaction  when  the  contents  contain  much  soluble  albumin. 

Dimethylamidoazobenzol,  methyl-violet,  and  tropasolin  00 
are  also  employed  as  free  hydrochloric  acid  reagents. 

A  very  sensitive  reagent  for  HCl  is  a  ^  per  cent,  alco- 
holic solution  of  dimethylamidoazobenzol.  This  yellowish 
solution  changes  to  a  reddish  color  on  the  addition  of  a  mere 
trace  of   free    HCl.     The   reaction    is  positive   with   an   HCl 


I04  DISEASES  OE  THE  STOMACH. 

solution  of  I  :  20,000.  The  reaction  is  also  produced  by 
concentrated  solutions  of  acid  phosphates  and  lactic  acid,  but 
such  concentrations  occur  so  rarely  and  in  such  particular 
conditions  as  to  allow  little  chance  for  an  error  to  be  made 
by  any  one  who  is  familiar  with  the  analysis  of  the  tjastric 
contents. 

Methyl-violet  is  changed  to  a  sky-blue  color  by  free  HCl. 
The  intensity  of  the  blue  color  produced  varies  with  the 
strength  of  the  hydrochloric  acid  solution — i  :  10,000  gives 
a  bluish  tinge,  and  i  :  5000  a  clear  reaction.  But  the 
reagent  is  not  so  sensitive  when  the  gastric  contents  are  em- 
ployed instead  of  an  aqueous  solution  of  HCl.  Lactic  acid, 
in  a  solution  of  i  :  300,  produces  also  a  bluish  tinge.  Chlo- 
rids  also  vitiate  the  results,  and  the  methyl-violet,  conse- 
quently, is  not  altogether  satisfactory  as  a  free  HCl  test.  The 
test,  which  is  a  very  pretty  one,  is  performed  in  the  following 
manner:  A  test-tube  full  of  a  very  dilute  solution  (1:500) 
in  distilled  water  is  prepared  (a  clear  violet  color),  and  two 
small  test-tubes  are  about  half  filled  with  it.  To  one  is  added 
one  to  three  c.c.  of  the  filtered  gastric  contents,  and  to  the 
other  the  same  quantity  of  distilled  water.  By  comparing 
the  two  tubes,  the  change  of  color  is  beautifully  displayed. 

Tropaeolin  00,  in  concentrated  aqueous  solution,  is  an 
excellent  reagent  for  detecting  free  acids,  but  it  is  not  quite  so 
sensitive  as  Congo-red.  The  yellow  solution  is  changed  to 
a  deep  red  by  free  acids.  Used  in  the  following  manner,  it  is 
a  sure  reagent  for  free  HCl  (Boas):  Three  or  four  drops  of 
a  saturated  alcoholic  solution  are  spread  thinly  in  a  porcelain 
crucible,  and  over  the  same  area  an  equal  quantity  of  the 
filtered  gastric  contents  is  allowed  to  flow.  Next,  heat  slowly 
over  a  small  flame.  If  free  HCl  is  present,  lilac  streaks 
appear  near  the  border,  which,  on  further  heating,  become 
blue. 

Whenever  free  HCl  is  present  in  the  gastric  contents,  it  is 
useless  to  make  a  test  for  HCl  in  combination  with  proteids, 
since  the  HCl  remains  free  only  when  the  acid  affinities  of 
the  proteids  have  already  been  satisfied.  The  presence  of 
HCl  free  proves  that  HCl  in  combination  with  proteids  is 
also  present. 

But  it  often  happens  in  the  diseases  of  the  stomach  that 
no  free  HCl  can  be  detected.  Under  such  circumstances,  if 
the  reaction  of  the  contents  is  acid,  HCl  in  proteid  combina- 
tion may  be  present.  To  detect  it,  qualitatively,  two  tests 
may  be  made,  one  of  which  is  a  chemical  and  the  other  a 
color  test.     A  small   quantity  of  the  filtered   contents   is  ex- 


THE  FUNCTIONAL   SIGNS.  IO5 

actly  neutralized,  boiled,  treated  with  acetic  acid  and  sodium 
chlorid,  again  boiled,  and  filtered  after  cooling.  Any  albu- 
min left  in  the  filtrate  is  digested  albumin  combined  with 
HCl.  A  positive  biuret  reaction  (rose)  on  treating  the  fil- 
tered contents  with  liquor  potassa  and  cupric  sulphate  shows 
the  presence  of  propeptones.  These  chemical  tests  also  give 
roughly  the  degree  of  peptonization.  The  color  test  is  made 
by  employing  a  one  per  cent,  aqueous  solution  of  alizarin. 
Three  or  four  drops  of  the  solution  of  the  dye  are  added  to 
a  small  quantity  of  the  filtered  contents,  and  decinormal 
alkaline  solution  is  added  until  a  pure  violet  color  appears.  To 
a  second  portion  of  the  filtered  contents  the  same  quantity  of 
the  alkaline  solution  is  added.  If  the  mixture  still  reacts  acid 
to  litmus,  HCl  in  proteid  combination  is  present.  For  prac- 
tical qualitative  purposes  the  biuret  test  is  sufficient. 

The  Quantitative  Analysis. — On  account  of  its  bearing 
on  the  diagnosis  and  treatment  of  the  diseases  of  the  stomach, 
an  easy  and  an  accurate  method  of  differentiating  and  esti- 
mating the  different  factors  of  the  acidity  of  the  gastric  con- 
tents is  very  desirable.  For  a  long  period  the  chemical 
analysis  was  confined  to  the  detection  of  free  hydrochloric 
acid.  Hayem  and  Winter  (1888)  proved  the  insufificiency  of 
this  method,!  and  gave  their  very  valuable,  but  long,  chloro- 
metric  analysis.  A  new  light  was  turned  on  the  chemical 
pathology  of  the  stomach.  Many  other  quantitative  methods 
have  since  been  given,  but  none  of  these  seem  completely  to 
satisfy  the  requirements  of  practice.  The  busy  physician  in 
his  daily  work  demands  a  quantitative  method  at  once  easy, 
accurate,  and  rapid. 

It  would  seem  that  the  practical  value  of  very  slight  quan- 
titative variations  in  the  factors  of  general  acidity  has  been 
overestimated,  and  that  the  simpler  color  methods  reveal  with 
sufficient  exactness  all  the  deviations  from  the  normal  chem- 
ism  which  possess  a  distinctive  practical  meaning.  The  in- 
accurate laboratory  methods  need  not  be  mentioned.  The 
more  complete  and  chemically  accurate  methods — which 
may  sometimes  be  used  with  advantage  in  practice,  and 
which  should  always  be  employed  in  original  research — will 
be  given.  Rut  for  daily  needs  coloration-titration  procedures 
usually  suffice. 

[a)  The  Color  Methods. —  The  Method  of  Mint.':. — This  method 
estimates  the  quantity  of  free  HCl,  or  H,  by  means  of  Giinz- 
burg's  reagent.  To  ten  c.c.  of  the  filtered  contents,  the  deci- 
normal alkaline  solution  is  added  from  the  buret  until  the 
reaction   of  a  droplet  (platinum   loop)  of  the  fluid  with   the 


I06  DISEASES  OF  THE  STOMACH. 

reagent  of  Giinzburg  becomes  negative.  If  the  reaction  is  still 
positive  with  0.9  c.c,  but  is  negative  with  i  .0  c.c.  of  the  titration 
alkali,  tiie  free  HCl  acidity  in  100  c.c.  of  the  gastric  contents 
is  represented  by  10  c.c.  of  the  decinormal  solution  of  caus- 
tic soda  or  potash.  One  c.c.  of  a  decinormal  alkaline  solution 
represents  0.00365  HCl ;  consequently,  the  100  c.c.  of  the 
gastric  contents  contain  ten  times  that  amount.  The  strong 
free  HCl  in  the  contents  is  first  completely  neutralized  by  the 
alkali  before  any  of  the  other  factors  of  the  total  acidity  are 
affected.  The  method  consumes  less  time  if  the  platmum 
loop,  wet  in  the  solution,  is  brought  in  contact  with  Congo- 
paper.  When  the  Congo-red  is  no  longer  made  markedly 
blue,  the  use  of  the  more  trustworthy  reagent  of  Giinzburg 
may  be  begun. 

The  Method  of  Boas. — The  object  of  this  method  is  the 
quantitative  estimation  of  the  free  hydrochloric  acid,  or  H, 
Five  c.c.  of  a  watery  solution  of  Congo-red  are  added  to  an 
equal  quantity  of  the  filtered  contents.  The  mixture  becomes 
blue.  The  titration  is  made  with  the  decinormal  solution  of 
caustic  potash  or  soda,  and  contin  ueduntil  the  original  Congo- 
red  color  is  restored.  As  a  control  color,  five  c.c.  of  the  Congo- 
red  solution  may  be  added  to  an  equal  quantity  of  distilled 
water.  The  titration  should  be  slow  near  the  end,  as  the 
restoration  of  the  red  color  does  not  take  place  rapidly. 

The  value  thus  found  represents  free  HCl  ;  or,  more  accur- 
ately, free  HCl  and  the  quantity  office  organic  acids  present, 
or  H  +  O.  The  author  of  the  method  claims  that  the  quan- 
tity of  organic  acids  in  the  contents  after  the  test-breakfast  is 
practically  seldom  worth  considering  when  free  HCl  is  pres- 
ent, but  that  if  the  organic  acids  are  present  in  notable  quan- 
ity,  they  should  be  removed  by  repeated  shaking  with  ether 
before  the  titration. 

Method  of  Topfer. — The  method  of  Topfer  requires  the  fol- 
lowing color  reagents:  (i)  One-half  per  cent,  alcoholic  solu- 
tion of  dimethylamidoazobenzol ;  (2)  one  per  cent,  aqueous 
solution  of  alizarin  ;  (3)  one  percent,  alcoholic  solution  of 
phenolphthalein. 

I.  To  ten  c.c.  of  the  filtered  contents  are  added  a  few  drops 
of  the  alcoholic  solution  of  phenolphthalein,  and  the  total 
acidity  is  titrated  with  a  decinormal  solution  of  caustic  potash 
or  caustic  soda.  The  alkali  is  to  be  added  until  the  rose-red 
coloration  is  permanent,  and  drop  by  drop  so  long  thereafter 
as  the  rose  color  does  not  become  deeper.  The  end  reaction 
of  the  color  indicator  is  used.  This  gives  the  total  acidity, 
or  A. 


THE   FUNCTIONAL    SIGNS.  IO7 

2.  To  ten  c.c.  of  the  filtered  contents  are  added  three  or 
four  drops  of  a  yi  pei'  cent.  alcohoHc  solution  of  dimethylam- 
idoazobenzol.  This  yellowish  solution  is  changed  to  red 
by  a  trace  of  free  HCi,  being  as  sensitive  as  the  reagent  of 
Giinzburg.  Organic  acids  (free)  produce  the  red  color  when 
in  a  concentration  of  0.5  per  cent,  and  in  the  presence  of 
mucin  and  albumoses  require  even  a  greater  concentration. 
Such  a  quantity  of  organic  acids  is  probably  never  present 
in  the  free  HCl-containing  contents  (qualitative  tests)  of  the 
test-breakfast,  given  on  a  clean  and  an  empty  stomach.  The 
titration  is  made  with  the  decinormal  alkaline  solution  until 
the  original  light  orange  (not  lemon  yellow)  replaces  the  red 
color  produced  on  the  addition  of  the  dimethylamidoazobenzol 
to  the  contents.  The  value  thus  obtained  represents  the  free 
HCI,  or  H. 

3.  To  ten  c.c.  of  the  filtered  contents  are  added  three  or 
four  drops  of  the  one  per  cent,  aqueous  solution  of  alizarin. 
This  reagent  is  sensitive  to  all  the  factors  of  gastric  acidity 
except  the  organic  combined  HCI,  or  C  ;  or,  in  other  words, 
the  alizarin  solution  becomes  pure  violet  on  the  addition  of 
the  solution  of  caustic  alkali  after  all  the  factors  of  gastric 
acidity  have  been  neutralized  except  C,  which  does  not  pre- 
vent the  transformation  of  color.  This  solution,  which  is 
yellowish,  becomes  brownish,  and  then  pure  violet,  as  the 
titration  proceeds.  As  soon  as  the  p2ire  violet  color — which  is 
the  same  as  that  produced  by  a  one  per  cent,  solution  of 
sodium  carbonate — appears,  the  titration  is  complete.  This 
value  gives  the  free  HCI  and  the  acidity  due  to  the  acid  salts 
and  the  organic  acids,  or  H  +  P  +  O,  A  —  (H  +  P  +  O) 
=  C.  A  —  (H  +  C)  =  O  -f  P.  (A,  total  acidity  ;  H,  free 
HCI ;  P,  acid  salts ;  O,  free  organic  acids ;  C,  HCI  com- 
bined with  proteids.)  The  quantity  of  the  decinormal  alkaline 
solution  used  in  each  titration  is  multiplied  by  10  to  bring 
all  to  the  standard,  which  is  lOO  c.c.  of  the  gastric  contents  ; 
or  it  is  better  to  use  only  five  c.c.  of  the  filtered  contents,  and 
to  multiply  the  results  by  20.  The  method,  after  practice, 
gives  good  results,  but  the  proper  use  of  the  alizarin  as  an 
indicator  requires  care  and  experience. 

Combination  Color  Method. — The  color  methods  may  be 
combined  in  such  a  manner  as  to  make  the  quantitative  esti- 
mate of  the  factors  of  acidity  of  the  gastric  contents  suffi- 
ciently complete  and  accurate  for  the  requirements  of  prac- 
tice. 

I.  If  the  qualitative  tests  have  revealed  the  presence  of  free 


108  DISEASES  OF  THE  STOMACH. 

hydrochloric  acid  in  the  gastric  contents,  we  may  proceed  as 
follows  : 

A  qualitative  test  for  free  volatile  organic  acids  should  be 
made.  An  acetic  or  a  rancid  odor  would  create  suspicion. 
A  small  quantity  of  the  contents  is  put  into  a  test-tube,  and 
a  strip  of  moistened  blue  litmus  paper  is  held  in  the  end  of 
the  tube  while  its  contents  are  gently  warmed.  The  litmus 
paper  will  be  reddened  if  a  volatile  acid  is  present.  Lactic 
acid  in  the  contents  of  the  stomach  containing  free  hydro- 
chloric acid  has  no  distinctive  pathological  significance,  and 
if  found  was  probably  introduced  as  such,  or  was  set  free  by 
decomposition  of  lactates  in  the  test-breakfast  or  in  the 
saliva.  On  the  other  hand,  acetic  and  butyric  fermentations 
are  frequent  in  the  presence  of  free  hydrochloric  acid. 

Ten  c.c.  of  the  filtered  or  well-mixed  unfiltered  contents 
are  placed  in  a  beaker,  and  the  titration,  with  a  decinormal  solu- 
tion of  caustic  potash  or  of  caustic  soda,  is  begun.  The  level 
of  the  solution  in  the  Mohr  buret  is  noted  on  a  piece  of 
paper  after  reading  the  mark  of  the  lowest  part  of  the  menis- 
cus, the  finger  being  placed  just  below  the  point  so  as  to  make 
the  demarcation  clearer.  The  decinormal  alkaline  solution  is  al- 
lowed to  flow  until,  after  shaking,  a  drop  taken  out  (conveni- 
ently with  a  platinum  loop)  gives  a  negative  reaction  with  a  few 
drops  of  a  i^  per  cent,  alcoholic  solution  of  dimethylamido- 
azobenzol  or  with  Giinzburg's  reagent.  The  point  where 
the  reaction  with  these  color  reagents  disappears  gives, 
when  read  on  the  buret,  the  quantity  of  decinormal  alkaline  so- 
lution req.uired  to  neutralize  the  free  HCl  contained  in  the  ten 
c.c.  of  the  contents.  A  memorandum  of  this  reading  is  made 
on  a  slip  of  paper.     This  gives  H.  or  the  quantity  of  free  HCl. 

A  droplet  of  the  contents  (platinum  loop)  is  now  brought 
into  contact  with  a  few  drops  of  an  aqueous  solution  of  Congo- 
red.  If  the  reaction  is  positive  (grayish-blue),  free  organic 
acids  are  present.  The  titration  is  continued  with  the  solu- 
tion of  Congo-red  as  indicator.  As  soon  as  the  reaction  fails, 
the  reading  of  the  buret  is  again  taken,  and  the  additional 
quantity  of  decinormal  solution  used  represents  the  quantity 
of  free  organic  acids.     Thus  O  is  obtained. 

A  droplet  of  the  contents  (platinum  loop)  is  next  brought 
into  contact  with  a  few  drops  of  a  one  per  cent,  aqueous  solution 
of  alizarin.  If  the  reaction  is  negative,  the  titration  is  con- 
tinued with  the  alizarin  as  indicator.  The  point  where  the 
pure  violet  reaction  begins  marks  the  disappearance;  of  the 
acid  salts.  The  reading  on  the  buret  is  again  taken,  and  a 
note  is  made  of  it.     This  gives  P. 


THE   FUNCTIONAL    SIGNS.  IO9 

The  remaining  acidity  is  titrated  after  the  addition  of  a  few 
drops  of  a  one  per  cent.  alcohoHc  solution  of  phenolphthalein. 
The  decinormal  alkaline  solution  is  added  until  there  is  no 
longer  an  increase  of  the  rose-red  color;  not  the  beginning 
but  the  end  reaction  is  taken  to  indicate  the  completion  of 
titration.  The  level  of  the  solution  is  again  read  on  the 
buret.  The  additional  quantity  of  decinormal  solution  used 
represents  the  acidity  due  to  HCl  in  organic  combination. 
This  is  C. 

The  total  quantity  of  the  decinormal  solution  used  repre- 
sents the  total  acidity  of  the  ten  c.c.  of  the  analyzed  contents. 

It  only  remains  to  calculate  the  acidity  represented  by  each 
factor  in  100  c.c.  of  the  gastric  contents — the  quantity  taken 
as  the  convenient  standard  of  comparison.  Ten  c.c.  being 
used  in  the  analysis,  the  results  are  all  multiplied  by  ten.  This 
gives  the  total  acidity  and  the  different  factors  of  it,  expressed 
in  so  many  cubic  centimeters  ot  decinormal  solution. 

After  experience  with  the  color  reagents,  the  analysis  can 
be  done  rapidly  without  using,  in  making  the  repeated  tests, 
a  sufficient  quantity  of  the  contents  materially  to  falsify  the 
results.  The  procedure  may  be  easily  controlled  by  repeating 
the  analysis,  or  part  of  it,  on  a  fresh  specimen. 

2.  If  there  be  no  free  HCl  but  free  organic  acids  in  the 
contents,  as  indicated  by  the  Congo-red,  tlie  test  is  made  as 
before  for  volatile  acids.  If  the  volatile  acids  are  absent,  the 
free  acidity  is  due  to  lactic  acid.  If  volatile  acids  are  present 
and  Uffelmann's  reaction  is  negative,  the  free  acidity  is  due  to 
acetic  or  butyric  acid,  or  to  both.  The  reactions  for  lactic  and 
volatile  acids  may  both  be  positive,  as  in  obstructive  retention 
in  carcinoma,  with  absence  of  free  HCl.  The  titration  is 
begun  with  Congo-red  as  the  indicator,  and  completed  with 
alizarin  and  phenolphthalein  as  before.  This  gives  O,  P, 
and  A.  C  may  be  incorrect,  on  account  of  the  possible  union 
of  organic  acids  with  the  proteids. 

3.  If  no  free  acid  is  present,  as  indicated  by  Congo-red,  the 
titration  begins  with  alizarin  and  is  completed  with  phe- 
nolphthalein. This  gives  P,  C,  and  A  ;  C  being  again  pos- 
sibly incorrect. 

If  the  contents  contain  no  free  HCl,  the  deficiency  of  HCl 
secretion  may  be  roughly  determined  by  the  method  of  von 
Noorden  and  Honigmann.  Decinormal  solution  of  HCl  is 
added  to  ten  c.c.  of  the  filtered  contents  until  the  reactions  for 
free  HCl  appear.  The  quantity  of  the  decinormal  solution 
of  HCl  represents  the  deficiency  in  the  secretion  of  hydro- 
chloric acid.     This  test  is  of  more  value  when  made  on  the 


I  lO  DISEASES  OF  THE  STOMACH. 

unfilteied  contents.  Congo-red  and  Giinzburg's  reagent 
slioiild  be  used  as  the  indicators.  If  free  organic  acids  are 
present,  these  should  be  estimated  first  and  neutrahzed.  The 
test  is  then  made  by  using  ten  c.c.  of  the  unfiltered  contents 
whose  free  acidity  has  been  neutralized.  The  decinormal 
solution  of  HCl  is  added  until  dimethylamidoazobenzol  (drop- 
let method)  or  Giinzburg's  reagent  reveal  the  appearance  of 
free  HCl.  The  quantity  of  the  decinormal  HCl  added  has 
been  used  in  the  formation  of  acid  proteid  compounds  and  in 
the  displacement  of  organic  acids.  Consequently,  after  the 
free  HCl  reaction  becomes  positive,  the  quantity  of  organic 
acids  set  free  must  be  estimated  by  further  titration  with  a 
decinormal  alkaline  solution  until  Congo-red  no  longer  gives 
a  reaction.  The  quantity  of  alkali  used  should  be  subtracted 
from  the  quantity  of  decinormal  HCl  obtained  in  the  first 
part  of  the  titration.  If  no  HCl  has  been  secreted  and  com- 
bined with  proteids,  the  two  titrations  will  give  the  same 
quantities,  all  the  decinormal  HCl  being  utilized  in  the  dis- 
placement of  organic  acids. 

{l>)  The  Chemical  Methods. — The  Method  of  Brmin. — The 
method  of  Braun  is  one  of  the  simplest  of  the  chemical 
methods.  The  general  acidity  (A)  of  ten  c.c.  of  the  filtered 
contents  is  estimated  by  titration  with  a  decinormal  potash 
or  soda  solution,  using  phenolphthalcin  as  the  indicator. 

To  a  second  ten  c.c.  of  the  filtered  contents,  in  a  platinum 
crucible,  is  added  a  decinormal  solution  of  potash  or  soda  in 
excess  of  the  general  acidity  as  given  by  the  first  analysis, 
and  this  quantity  is  noted.  The  alkaline  fluid  is  ne.xt  evapo- 
rated carefully  on  an  asbestos  plate,  and  the  residue  is  incin- 
erated, care  being  taken  not  to  heat  the  crucible  beyond  a 
dull  red  glow,  and  to  stop  as  soon  as  no  more  points  are  in 
ignition.  The  ashes  are  next  dissolved  with  a  quantity  of 
decinormal  H2SO,  (or  HCl)  solution  equal  to  that  of  the 
decinormal  potash  or  soda  solution  added  before  evapo- 
ration. The  solution  is  next  warmed  to  drive  off  the  CO2, 
and  titrated  with  phenolphthalcin  and  decinormal  KOH,  or 
NaOH.  This  gives  the  total  acidity,  with  the  exception 
of  that  due  to  the  burnt  organic  acids,  or  H  -}-  C  +  P.  A  — 
(H  -f  C  -j-  P)  =  O.  For  example,  ten  c.c.  of  the  filtered 
contents  require  six  c.c.  of  the  decinormal  K(OH)  to  neutral- 
ize it.  or  60  per  100  c.c.  This  gives  A  =  60  decinormal 
K(OH).  To  a  second  ten  c.c.  of  the  contents  are  added  seven 
c.c.  decinormal  K(OH);  this  is  then  evaporated,  incinerated, 
and  seven  c  c.  decinormal  HoSO,  (or  HCl)  added,  and  the  dis- 
solved ash,  after  heating,  requires  five  c.c.  decinormal  K(OH) 


THE   FUNCTIONAL    SIGNS.  1 1  I 

for  neutralization.  C  +  H  +  P  =  50  decinormal  K(OH);  6o 
—  50  =  10  =  O,  or  the  organic  acids  converted  into  alkaline 
carbonates  by  incineration  and  combined,  with  the  equivalent 
acid  added.     This  method  gives  O  (C  +  H  +  P)  and  A. 

The  Mctlwd  of  Hayein  and  Winter. — The  method  of  tlayem 
and  Winter  is  very  long,  but  when  well  carried  out  is  also 
very  accurate  for  H  +  C. 

In  three  porcelain  capsules,  a,  b,  and  c,  are  placed  five  c.c. 
of  filtered  gastric  contents. 

To  the  capsule  a  is  added  an  excess  of  pure  carbonate  of 
soda,  and  then  the  contents  of  the  three  capsules  are  slowly 
evaporated  to  complete  dryness  on  the  water-bath.  The 
capsule  a,  to  which  the  carbonate  of  soda  was  added,  con- 
tains all  the  chlorin  of  the  gastric  juice  in  the  form  of  inor- 
ganic chlorids.  The  capsule  a  gives  the  total  chlorin,  or  T. 
The  capsule  is  next  brought  to  a  low  red  heat,  slowly  and 
frequently  stirring  with  a  glass  rod,  so  as  to  avoid  loss  by 
little  explosions.  As  soon  as  no  more  points  are  in  ignition 
and  the  carbonate  of  soda  begins  to  fuse,  the  incineration  is 
completed.  After  cooling,  the  residue  is  taken  up  with  dis- 
tilled water,  to  which  a  little  pure  nitric  acid  has  been  added. 
The  solution,  which  should  be  clear,  is  next  boiled  to 
drive  off  the  CO2.  It  is  then  completely  neutralized,  or  ren- 
dered slightly  alkaline  with  pure  carbonate  of  soda.  Heat 
until  an  abundant  precipitate  falls,  taking  down  the  carbon 
with  it.  Then  filter,  wash  the  precipitate  with  boiling  water, 
unite  all  the  washings,  and  estimate  the  quantity  of  chlorin 
with  decinormal  AgNOa  in  the  presence  of  neutral  chromate 
of  potash.  One  or  two  drops  of  a  concentrated  solution  of 
neutral  chromate  of  potash  are  added  to  the  filtrate,  and  the 
decinormal  solution  of  nitrate  of  silver  is  allowed  to  flow 
into  it  from  the  buret  until  the  red  coloration,  after  shaking, 
remains  permanent.  All  the  chlorin  is  now  combined, 
and  the  silver  begins  to  unite  with  the  chromic  acid.  The 
titration  is  complete.  The  number  of  cubic  centimeters  of  the 
decinormal  silver  solution  multiplied  by  O.073  (20  X  O.OO365) 
expresses  in  terms  of  HCl  the  quantity  of  chlorin  contained 
in  100  c.c.  of  the  gastric  contents. 

The  capsules  band  c,  by  the  prolonged  and  complete 
evaporation  at  100°  C,  have  been  deprived  of  their  HCl  (free). 
To  the  capsule  b  we  add  an  excess  of  carbonate  of  soda,  and 
fix  the  remaining  chlorin.  We  proceed  as  with  the  first 
capsule,  and  estimate  the  quantity  of  chlorin  :  a  —  b  =  H,  or 
free  HCl. 

The  contents  of  the  capsule  c  are  incinerated  without  the 


112  DISEASES  OF  THE  STOMACH. 

addition  of  carbonate  of  soda.  The  process  is  rapidly  done 
by  heating  on  a  wire  gauze  while  breaking  the  coal  with  a 
glass  rod.  As  soon  as  the  coal  is  dry  and  friable,  the  process 
is  complete.  After  cooling,  treat  as  capsule  a.  This  capsule 
contains  only  the  fixed  inorganic  chlorids.  The  free  HCl 
has  been  driven  off  and  the  combined  HCl  (C)  destroyed  by 
heat :  b  —  c  =  C,  or  organic  combined  HCl  ;  a  =  T ;  a  — 
b  =  H;  b  —  c  =  C;  c^:=:F,  or  inorganic  combined  chlorin. 

This  is  a  chlorometric  method.  The  values  found  may  be 
converted  into  their  HCl  equivalents,  or  multiplied  by  20  to 
give  the  equivalent  quantities  of  decinormal  A gNO.j  required  to 
combine  each  chlorin  factor  in  100  c.c  of  gastric  contents. 

In  the  analysis  of  Hayem  and  Winter,  the  quantity  obtained 
for  b  (C  +  F)  is  incorrect.  Not  all  the  free  HCl  is  driven 
off  by  evaporation,  and  the  heating  causes  more  of  the  free 
HCl  which  is  present  to  combine  with  the  proteids.  But  a 
(=  T)  and  c  (^  F)  are  correct.  T  —  F  =  H  -f-  C.  In 
case  no  free  HCl  is  present,  T  —  F  =  C.  If  the  contents 
contain  free  HCl,  the  quantity  should  be  estimated  by  Giinz- 
burg's  reagent,  or  by  Topfer's  dimethylamidoazobenzol,  which 
would  give  H. 

The  Method  of  L'uttke. — Like  that  of  Hayem  and  Winter, 
the  method  of  Liittke  is  chlorometric.  The  total  chlorin 
(T)  and  the  chlorin  combined  with  inorganic  bases  (F)  are 
quantitatively  estimated.  The  difference,  or  T  —  F,  repre- 
sents the  physiologically  active  chlorin  (H  +  C) — i.e.,  the 
quantity  of  secreted  HCl  left  free  (H)  and  combined  with 
proteids  (C). 

The  chlorin  is  estimated  by  the  method  of  Volhard.  For 
this  purpose  are  needed  :  (i)  A  decinormal  acid  solution  of 
pure  nitrate  of  silver  and  (2)  a  decinormal  solution  of  ammo- 
nium sulphocyanid. 

The  decinormal  acid  silver  nitrate  solution  is  prepared  by 
the  following  formula: 

Argenti  nitras  (c.  p. ), 17.5  gm. 

Acidiim  sul|iburicum  {25  ]>er  cent,  solution), 900.    c.c. 

Liquor  ferri  sulplniiici  oxidati, 50.     c.c. 

Mix  and  dissolve  in  the  above  order,  and  add  enough  distilled 
water  to  make  one  liter.  Correct  by  using  a  standard  deci- 
normal solution  of  HCl.  Ten  c.c.  of  the  silver  solution  are 
measured  and  diluted  to  100  or  150  c.c.  with  distilled  water. 
This  dilution  is  titrated  \Vith  the  decinormal  solution  of  HCl. 
If,  for  e.xample,  9.5  c.c.  of  the  HCl  solution  are  required 
to  exactly  combine  the  silver  in  the    10  c.c.  taken,  950  c.c.  of 


THE   FUNCTIONAL    SIGNS.  I  I  3 

the  acid  silver  solution  are  diluted  to  lOOO  c.c,  and  the  cor- 
rection is  confirmed  by  a  new  titration. 

The  decinormal  solution  of  the  sulphocyanid  of  ammo- 
nium is  prepared  by  adding  eight  gm.  of  NH4CNS  to  a  liter 
of  distilled  water,  and  the  solution  is  corrected  by  means  of 
the  decinormal  silver  solution.  If,  for  example,  9.8  c.c.  of  the 
decinormal  silver  solution  are  required  to  produce  the  first 
light  rose  color,  persisting  after  shaking,  980  c.c.  of  the  solu- 
tion are  diluted  to  lOOO  c.c,  and  the  correction  confirmed  by 
titration,  until  the  quantity  of  CNS  in  one  c.c.  of  the  one  is 
just  sufficient  exactly  to  combine  the  quantity  of  Ag  in  one 
c.c.  of  the  otl'^er. 

If  the  acid  silver  solution  is  added  in  excess  to  the  gastric 
contents,  only  so  much  of  the  silver  is  precipitated  as  chlorid 
of  silver  as  there  is  chlorin  present  to  combine  with  it.  The 
unchanged  nitrate  of  silver  is  estimated  by  titration  with  the 
decinormal  solution  of  ammonium  cyanid,  after  removal  of 
the  precipitated  chlorid  of  silver  by  filtration.  When  the 
cyanid  is  added  to  the  acid  solution  containing  the  nitrate  of 
silver  and  sulphate  of  iron,  cyanid  of  silver  and  the  cyanid 
of  iron  are  formed. 

AgNO^  +  NH.CNS  =  AgCNS  +  NH^NO^. 
Fe,(S6j3  +  6NH,CNS  =  Fe.,(CNS)e  +  3lNHJ,SO,. 

The  cyanid  of  iron  colors  the  solution  blood-red,  but  so 
long  as  AgNOs  is  present,  Fe2(CNS)c  is  decomposed  and 
AgCNS  formed,  and  the  red  color  disappears.  The  first  per- 
sistence of  a  rose  color  indicates  that  all  the  nitrate  has  been 
converted  into  the  cyanid  of  silver,  and  the  quantity  of  the 
decinormal  solution  of  ammonium  sulphocyanid  used  rep- 
resents the  quantity  of  silver  nitrate  unconverted  into  the 
chlorid  of  silver. 

I.  The  Analysis. — Ten  c.c.  of  the  ivcll-inixed  7in filtered  gas- 
tric contents  are  placed  in  a  100  c.c.  graduate,  a,  and  the 
measure  graduate  is  washed  out  a  number  of  times  with  dis- 
tilled water,  the  washings  being  poured  into  the  large  gradu- 
ate. Twenty  c.c.  of  the  decinormal  acid  solution  of  nitrate  of 
silver  are  added,  the  mixture  is  well  shaken,  and  left  standing 
for  ten  minutes.  All  the  chlorin  contained  in  the  specimen 
combines  with  the  silver  and  forms  the  insoluble  chlorid. 
Other  combinations  of  silver  are  prevented  by  the  presence  of 
the  H2SO4.  Next,  add  enough  distilled  water  to  make  the 
mixture  measure  exactly  100  c.c,  and  filter,  using  dry  paper, 
a  dry  funnel,  and  a  dry  beaker.  Fifty  c.c.  of  the  filtrate  are 
titrated  with  the  decinormal   solution   of  ammonium   sulpho- 


I  14  DISEASES  OF  THE  STOMACH. 

cyanid,  tlie  titration  bein<^  complete  as  soon  as  tlie  reddish 
color  persists  after  shaking.  The  reading  on  the  buret  is 
taken,  and  gives  one-half  of  the  silver  nitrate  added  in  excess. 
The  reading,  multiplied  by  two  and  subtracted  from  20,  gives 
the  total  quantity  of  chlorin  present  in  the  ten  c.c.  of  the 
gastric  contents.  If,  for  example,  six  c.c.  of  the  titration  fluid 
have  been  used,  six  multiplied  by  two  and  the  product  sub- 
tracted from  twenty,  gives  eight  c.c.  to  represent  the  total 
chlorin,  or  T;  0.00355  multiplied  by  eight,  or  0.0284  gm.  of 
chlorin,  in  the  ten  c.c.  of  gastric  contents,  or  0.00365  X  8  = 
0.0292  gm.  of  HCl.     Thus  T  is  estimated. 

2.  A  second  ten  c.c.  of  the  mixed  unfiltered  contents  are 
placed  in  a  platinum  crucible,  b,  and  evaporated  (best  on  an 
asbestos  plate).  The  residue  of  evaporation  is  incinerated  by 
holding  the  crucible  directly  in  the  flame  until  the  organic 
matter  no  longer  burns  and  there  is  a  dull  red  glow.  The 
incinerating  should  be  done  rapidly  and  without  overheating, 
as  high,  prolonged  heat  would  also  decompose  the  inorganic 
chlorids.  The  free  and  combined  HCl  (H  +  C)  has  been 
driven  off  by  the  evaporation  and  incineration,  and  the  ash 
contains  only  the  inorganic  chlorids. 

Pathologically,  large  quantities  of  ammonium  chlorid  (as  in 
uremia,  putrefaction,  etc.)  and,  normally,  traces  of  this  salt,  are 
found  in  the  contents  of  the  stomach.  The  ammonium  chlorid 
is  decomposed  and  driven  off  by  incineration,  and  thus  es- 
capes estimation.  The  quantity  of  inorganic  chlorids  will  be 
just  as  much  too  small,  and  the  remainder,  T  —  F  or  H  + 
C,  too  great,  the  ammonium  chlorid  being  included  in  the 
estimate  of  T.  This  is  a  possible  source  of  error,  which  does 
not  exist  with  T  and  F  in  the  method  of  Hayem  and  Winter. 

The  ash  is  next  dissolved  by  rubbing  repeatedly  with  hot 
water,  the  extraction  fluid  being  emptied  upon  a  filter.  About 
200  c.c.  of  hot  water  are  required,  and  a  small  quantity  of  the 
last  washing  should  give  no  precipitate  with  the  silver  solu- 
tion. The  whole  of  the  filtered  washing,  after  the  addition  of 
ten  c.c.  of  the  decinormal  silver  solution  and  filtration,  are 
titrated  with  the  decinormal  solution  of  ammonium  cyanid, 
and  the  value  found  is  subtracted  from  ten.  The  remainder 
is  the  value  for  the  inorganic  chlorids  (except  chlorid  of  am- 
monium, if  it  should  have  been  present).  Thus  F  is  estimated. 
If,  for  examjile,  seven  c.c.  of  the  titration  fluid  were  used, 
seven  subtracted  from  ten  gives  three  :  O.OO355  X  3  =  0.01065 
gm.  chlorin,  or  0.00365  X  3  ==  O.OIO95  gm.  free  HCl  in  the 
ten  c.c.  of  gastric  contents. 

The  total  acidity,  A,  is  estimated  by  phenolphthalein.     The 


THE   FUNCTIONAL   SIGNS.  II5 

free  acidity,  B,  is  estimated  by  using  a  ten  per  cent,  solution 
of  tropaeolin  in  dilute  alcohol  as  the  indicator,  in  the  same 
manner  as  phenolphthalein,  the  yellow  mixture  changing  to 
red  as  soon  as  the  titration  is  completed.  T  —  F  =  H  -f"  C. 
A— (H  +  C)=0+P.  If  A  =T  — F,  then  B=H.  If 
A  >  T  —  F,  organic  acids  are  present.  If  B  =:  A  —  (T  —  F), 
all  the  HCl  is  combined,  and  all  the  organic  acids  are  free. 
IfB<A  —  (T  —  F), all  the  HCl  and  a  part  of  the  organic 
acids  are  combined;  the  free  acidity,  B,  consists  wholly  of 
free  organic  acids.  If  B  >  A  — (T  —  F),  free  organic  acid  and 
free  HCl  are  present,  all  the  organic  acids  being  uncombined. 

Many  other  chemical  methods  have  been  employed.  These 
either  have  only  a  historical  interest,  or  possess  no  advan- 
tages over  the  three  methods  already  given.  We  recommend 
the  method  of  Braun  for  the  estimation  of  the  organic  acids, 
or  O.  The  method  of  Hayem  and  Winter  gives  the  most 
accurate  results  for  T  and  F,  and  consequently  for  T — F,  or 
H  -t-  C.  The  free  HCl,  or  H,  should  be  directly  estimated  by 
Giinzburg's  reagent.  The  total  acidity,  or  A,  is  estimated  by 
using  phenolphthalein  as  the  indicator. 

The  knowledge  of  the  percentages  of  HCl  in  the  contents 
is  usually  sufficient.  But  the  total  quantity  of  physiological 
HCl,  or  H  -|-  C,  in  the  stomach  at  a  given  moment  gives 
some  further  information  concerning  the  activity  of  secretion 
and  of  the  motor  and  absorptive  functions.  The  absolute 
quantity  of  HCl  in  the  stomach  at  the  time  of  the  removal  of 
the  contents  may  be  easily  calculated  from  the  analysis  of 
a  part,  provided  the  whole  quantity  of  the  contents  is  known. 
The  total  quantity  of  the  contents  can  be  determined  by  the 
acidity  method  of  Mathieu  and  Remond  or  by  the  specific 
gravity  method  of  Strauss. 

TJie  Diagnostic  Value  of  the  Variations  of  HCl. — By  some 
students  the  chemical  types  revealed  by  the  analysis  of  the 
gastric  contents  after  a  test-meal  have  been  considered  dis- 
tinct diseases.  These  diseases  have  been  carefully  described, 
and  each  of  them  has  been  supplied  with  a  characteristic 
etiology,  symptomatology,  evolution,  and  treatment.  Others 
give  the  chemical  types  a  place  among  the  complications,  and 
speak  of  the  various  anatomical  diseases  complicated  by  this 
or  that  chemical  variation.  Neither  of  these  opinions  can  be 
successfully  defended,  as  the  cheniical  types  are  only  reveal- 
ing signs  or  symptoms. 

Furthermore,  these  chemical  signs  have  no  pathognomonic 
meaning.  Neither  a  dynamic  affection,  nor  cancer,  nor  ulcer, 
nor  gastritis,  are  constantly  associated  with  a  particular  varia- 


Il6  DISEASES  OF  THE  STOMACH. 

tion.  Hayem  contends  that  in  all  gastric  troubles  with  per- 
sistent chemical  types  there  are  anatomical  changes,  and 
often  serious  lesions  of  the  mucous  membrane;  that  the  work 
of  the  stomach  is  compromised,  like  that  of  other  organs,  only 
when  there  is  an  anatomical  disease.  That  the  persistent 
chemical  types  have  often  a  physical  basis  in  histological 
pathology  is.  without  question,  true.  That  such  a  basis  always 
exists  is  more  than  doubtful,  for  normal  secretion  depends 
not  on  the  integrity  of  the  gastric  glands  only,  but  also  on  a 
normal  nerve-  and  blood-supply,  on  a  normal  motor  function, 
and  on  normal  absorption.  The  mucous  membrane  may  be 
perfectly  normal,  and  the  secretion  of  HCl  be  abnormal  and 
this  abnormality  may  be  the  symptomatic  expression  of  a  dis- 
ease which  is  not  located  in  the  stomach.  But  Hayem  has 
rendered  an  inestimable  service  in  searching  for  the  physical 
basis  of  the  chemical  types,  and  by  controlling  the  functional 
chemical  signs  by  the  revelations  of  autopsies. 

That  none  of  the  chemical  signs  are  pathognomonic,  is  no 
evidence  against  their  diagnostic  value,  which  may  be  both 
positive  and  negative. 

I.  The  analysis  of  the  gastric  contents  removed  after  a  test- 
meal  may  give  a  normal  quantity  of  free  and  combined  HCl 
(H  -f-  C),  or  the  quantity  may  be  variable,  notably  increased  or 
diminished,  or  the  physiological  HCl  may  be  entirely  absent. 

If  the  quantity  is  normal,  and  if  this  has  been  proven  by 
two,  or,  better,  by  three  t^sts,  made  with  two  or  three  days' 
intervals,  there  is  no  anatomical  disease  of  the  glands  of  the 
stomach.  The  condition  of  the  blood,  of  the  nerve-cen- 
ters controlling  secretion,  and  of  the  secreting  glands,  is  such 
as  to  allow  the  performance  of  the  normal  work.  There  may 
be  myasthenia  or  neurasthenia  gastrica,  but  it  is  more  proba- 
ble that  the  trouble  of  which  the  patient  complains  is  located 
in  the  intestines  or  some  other  organ.  Normal  digestive 
chemistr}'  excludes  with  certaint}'  an  extensive  disease  of  the 
mucous  membrane  of  the  stomach,  and  may  be  an  important 
sign  in  the  differential  diagnosis  of  the  diseases  of  other 
organs  from  one  another  and  from  the  diseases  of  tlie  stomach. 
These  may  be  autotoxic,  reflex,  cerebral,  spinal,  or  may  be 
due  to  disorders  of  the  circulation  or  to  the  quality  of  the 
blood.  Under  the  circumstances,  the  acid  secretion  will  at 
times  be  normal,  and  at  other  times  abnormal.  Variable  ab- 
normal types  are  common  in  chronic  gastritis,  with  acute  ex- 
acerbations. Any  form  of  variable  chemism  may  be  found  in 
complicated  myasthenia. 

Excessive  secretion  of  HCl  is  a  sign  of  adenohypersthenia 


THE   FUNCTIONAL    SIGNS.  WJ 

gastrica,  and  indicates  the  employment  of  sedative  medica- 
tion and  the  protection  of  the  mucous  membrane  against  the 
irritating  contents.  This  is  a  frequent  symptom  of  chronic 
glandular  gastritis,  or  it  may  be  associated  with  a  complicated 
myasthenia.  In  myasthenia  it  may  exist  as  an  expression  of 
the  irritation  produced  by  the  prolonged  sojourn  of  the  con- 
tents in  the  stomach  ;  in  a  further  stage  of  the  same  trouble 
there  may  be  continuous  secretion,  and  the  stomach  may  be 
unable  to  obtain  physiological  rest.  In  the  irritative  stage  of 
acute  mycotic  gastritis,  and  during  the  acute  exacerbations  of 
chronic  gastritis,  excessive  acidity  maj^  manifest  the  glandular 
irritability.  It  is  also  the  most  common  chemical  sign  of 
ulcer,  or  of  its  associated  gastritis.  Excessive  secretion  may 
occur  as  a  dynamic  affection,  as  in  the  crises  of  cerebrasthenia, 
tabes,  myelitis,  intestinal  auto-intoxication,  and  uricemia,  and 
may  rarely  be  a  symptom  of  carcinoma  engrafted  on  an  old 
ulcer. 

Hydrochloric  subacidity  is  a  common  sign  of  stages  or 
forms  of  acute  and  chronic  asthenic  gastritis,  of  carcinoma, 
sometimes  of  ulcer,  and  of  a  large  number  of  diseases  of  other 
organs,  of  the  blood,  and  of  disorders  of  the  circulatory  sys- 
tem. It  is  an  asthenic  sign,  and  may  indicate  the  employ- 
ment of  excitant  treatment. 

Hydrochloric  anacidity  is  exceedingly  rare  as  a  symptom 
of  a  dynamic  affection  of  the  stomach,  but  is  somewhat  com- 
mon in  forms  of  gastritis  and  in  atrophy.  Carcinoma  rarely 
runs  its  course  without  the  appearance  of  this  sign. 

The  analysis  of  the  acidity  of  the  contents  removed  at  the 
acme  of  digestion  of  the  test-meals  reveals  one  form  of  the 
quantitative  variations  of  the  hydrochloric  acid  secretion.  But 
secretion  may  also  be  disordered  in  its  evolution. 

In  order  to  detect  the  abnormal  evolution  of  gastric  diges- 
tion, it  is  necessary  to  extract  the  contents  at  various  intervals 
during  the  digestion  of  the  test-meal.  For  the  test-breakfast, 
the  intervals  should  not  be  longer  than  half  an  hour,  while 
the  extraction  should  take  place  from  hour  to  hour  when  the 
test-meals  of  See  and  Riegel  have  been  given,  removing  each 
time,  preferably  by  aspiration,  only  enough  of  the  contents 
for  analysis  ;  or  the  same  test-meal  may  be  given  on  succes- 
sive days  and  the  contents  be  removed,  by  expression,  after 
increasing  intervals,  until  the  evolution  of  digestion  is  com- 
pletely displayed.  A  test-meal  should  never  be  given  when 
the  stomach  is  not  empty,  and  gastric  retention  renders  it 
imperatively  necessary  to  first  employ  thorough  lavage,  which 
may  have  to  be  repeated  for  several  days  in  succession  until 


Il8  DISEASES  OF  THE  STOMACH. 

the  secretorx'  irritation  due  to  retention  subsides.  This 
stringent  rule  must  be  observed  with  special  care  when  inves- 
tigating the  evolution  of  digestion. 

The  evolution  of  secretion  maybe  more  rapid  than  normal. 
Expression  after  one  hour  may  give  only  a  small  quantity  of 
contents  advanced  in  digestion  and  a  somewhat  less  than 
normal  acidity.  The  stomach  is  almost  empty  and  digestion 
is  in  its  decline.  The  evolution  has  been  more  rapid  than 
normal,  and  the  tube,  introduced  twenty  minutes  after  the 
test-breakfast,  or  one  hour  after  the  test-meal  of  See,  or  two 
hours  after  the  test-dinner  of  Riegel,  will  show  that  at  this 
early  period  the  secreted  h}'drochloric  acid  remains  free.  This 
rapid  evolution  of  secretion  is  the  expression  of  a  morbid  irrita- 
bility or  excitability  of  the  glands,  accompanied  by  the  rapid 
evacuation  of  the  contents  of  the  stomach  ;  or  the  rapid  evolu- 
tion of  digestion  may  be  due  solely  to  the  rapid  empt\-ing  of 
the  stomach,  as  may  occur  in  incontinence  of  the  pylorus,  in 
forms  of  scirrhus,  in  some  cases  of  chronic  asthenic  and 
chronic  atrophic  gastritis,  and  in  hypermotility.  Secretion 
ceases  too  soon  because  the  stomach  becomes  empty  too 
rapidly.  Consequently,  the  too  rapid  evolution  of  digestion 
may  be  accompanied  b\^  hyperchylia.  by  h\-pochylia,  or  by 
achylia,  but  the  abnormally  rapid  evolution  of  secretion  is 
the  expression  of  morbid  activity  of  the  glands  and  it  may  be 
manifested  by  hyperchlorhydria  or  by  hyperchylia.  Abnor- 
mally rapid  secretion  never  occurs  in  adenasthenia.but  it  may 
occur  when  the  duration  of  digestion  is  short,  or  normal,  or 
long. 

The  evolution  of  secretion  may  be  prolonged,  and  the  pro- 
longation may  be  due  to  excessive  secretion,  to  continuous 
secretion,  to  myasthenia,  or  to  obstruction  of  the  pylorus  or 
duodenum.  All  three  stages  of  digestion  may  be  prolonged, — 
the  rise,  the  stationary  period,  and  the  decline, — being  long,  but 
regular,  in  their  general  characters.  This  disorder  of  evolution 
is  due  to  excessive  secretion  ;  or  the  period  of  decline  may 
be  abnormally  long  on  account  of  the  failure  of  secretion  to 
subside  as  the  stomach  evacuates  its  ingested  contents,  the 
lines  representing  the  evolution  of  digestion  being  regular: 
the  first  two  stages  of  digestion  may  be  long  or  short,  and 
accompanied  by  normal  or  excessive  hydrochloric  acidity. 
This  disorder  of  evolution  which  is  manifested  by  prolonged 
or  continuous  secretion  is  due  to  chronic  proliferating  glan- 
dular gastritis.  Prolonged  digestion  may  be  due  to  excessive 
or  to  continuous  secretion  ;  it  is  never  produced  by  adenas- 
thenia  ;  or  prolonged  digestion   may  be  due  to  motor  insufifi- 


THE   FUNCTIONAL    SIGNS.  I  1 9 

ciency,  and  the  evolution  of  digestion  will  show  sudden  rises 
and  falls,  which  display  the  irregularity  of  the  evacuation  of 
the  contents  of  the  stomach.  (For  the  disordered  evolution 
of  secretion  and  digestion  due  to  myasthenia  and  to  obstruc- 
tion, see  the  chapters  on  these  diseases.)  The  lower  the 
specific  gravity  of  the  contents,  the  greater  is  the  proportion 
of  gastric  juice  in  the  mixture.  The  specific  gravity  of  the  fil- 
trate of  the  normal  contents,  one  hour  after  the  test-breakfast, 
varies  from  loioto  1015  ;  and  the  specific  gravity  of  the  gastric 
juice  is  1004  to  1006.  In  excessive  secretion, the  specific  gravity 
of  the  contents  is  less  than  loio;  and  when  secretion  is  dimin- 
ished, the  specific  gravity  of  the  contents  one  hour  after  the 
test-breakfast,  provided  there  be  no  myasthenia,  is  near  1020. 

The  evolution  of  secretion  may  be  delayed.  The  contents 
removed  after  one  hour  show  no  free  HCl,  or  a  mere  trace  of 
it.  After  the  expiration  of  two  hours  (test-breakfast),  the 
quantity  of  the  contents  removed  is  larger  than  normal,  di- 
gestive products  are  comparatively  abundant,  and  the  free 
HCl  and  combined  HCl  are  both  greater  than  given  by  the 
standard  after  one  hour.  There  is  myasthenia,  or  obstruc- 
tion, with  irritation  from  stagnation. 

The  functional  signs  furnished  by  the  variations  of  the  acid 
secretion  should  not  in  themselves  be  given  too  distinct  a  diag- 
nostic meaning,  but  should  be  considered  in  connection  with 
the  other  diagnostic  signs.  Used  in  this  way,  their  diagnostic 
and  therapeutic  importance  and  value  become  at  once  appar- 
ent. 

2.  THE  FERMENTS. 

The  gastric  juice  contains  two  ferments,  the  quantity  and  the 
quality  of  which  vary  in  the  diseases  of  the  stomach.  These 
variations  can  only  be  roughly  detected  and  estimated,  but 
when  there  is  an  extreme  and  constant  deficiency  or  excess 
the  examination  gives  most  valuable  information  concerning 
the  anatomical  state  of  the  glandular  layer.  Slight  persistent 
quantitative  variations  may  suggest  the  direction  in  which  the 
disease  is  making  its  inroads. 

The  great  diagnostic  value  of  the  quantitative  estimation 
of  the  labferment  and  of  labzymogen,  and  of  pepsin  and 
pepsinogen,  is  not  admitted  nor  utilized  by  all  clinicians. 
As  a  result  of  careful  clinical  study,  we  wish  to  emphasize 
the  great  practical  utility  of  a  knowledge  of  their  quantita- 
tive variations. 

The  secretion  of  hydrochloric  acid  is,  probably,  the  work 
of  the  border  cells ;  but  this  biological  work  is  conditioned 


I20  DISEASES  OE  THE  STOMACH. 

and  intluencctl  by  so  many  circumstances  as  to  make  it  im- 
possible and  erroneous  to  attribute  the  variations  of  this  se- 
cretion to  diseases  of  the  cells  themselves.  The  quantitative 
variations  of  the  hydrochloric  acid  may  be  as  great  in  the 
dynamic  affection  as  in  the  anatomical  diseases.  This  secre- 
tion is,  besides,  intermittent,  and  called  forth  by  special 
excitation  at  recurring  intervals. 

The  chief  cells  perform  their  biological  work  in  a  different 
manner.  The  secretion  of  the  mother  substances  of  the  two 
active  ferments  displays  the  activity  of  the  cell  itself  The 
formative  work,  being  continuous,  is  less  directly  the  expres- 
sion of  digestive  influences.  Consequently,  we  do  not  find 
clinically,  at  least  with  the  tests  now  employed,  notable  and 
persistent  variations  which  are  purely  dynamic,  or  which  are 
due  to  a  disturbance  of  the  circulation,  like  passive  conges- 
tion. Clinically,  a  persistent  deficiency  and  an  excess,  re- 
vealed by  the  tests  now  in  use,  are  found  only  when  the  cells 
are  diseased. 

The  form,  however,  in  which  the  ferments  are  found  is  due 
to  circumstances.  The  conversion  of  the  mother  substance 
into  the  active  ferment  is  dependent  on  the  presence,  in  the 
stomach,  of  the  chemical  reagents  capable  of  producing  the 
change.  Consequently,  it  would  be  a  mistake  to  attribute 
the  variations  of  the  quantity  of  pepsin  and  labferment  to  im- 
perfect work  of  the  chief  cells.  But  we  must  consider  the 
deficient  formation  of  the  mother  substances,  of  which  the 
ferments  are  the  converted  products,  as  evidence  of  disease  of 
the  cells,  which  are  concerned  in  their  production.  The  fer- 
ments may  be  absent  when  their  prototypes  are  present  in 
normal  quantity.  In  such  a  case  we  must  look  for  an  ex- 
planation of  the  abnormality  elsewhere  than  in  the  ferment- 
secreting  cells. 

{a)  The  Labferment  and  Labzymogen, — Labzymogen  is 
probably  a  specific  secretion  of  the  chief  cells,  which  bj'  the 
action  of  weak  free  acids  and  of  calcium  chlorid  is  con- 
verted into  the  active  labferment.  The  ferment  is  rapidly 
destroyed  in  alkaline  fluids,  but  the  mother  substance  remains 
intact.  The  presence  of  calcium  salts  promotes  and  seems 
essential  to   the  milk-curdling  action  of  the  ferment. 

The  labferment  coagulates  milk  by  the  disintegration  of 
the  casein.  The  coagulation  differs  widely  from  that  of  acids, 
and  takes  place  in  the  presence — but  independently — of  any 
free  acid  in  the  stomach.  The  coagulation  which  is  produced 
eii  )iiassi\  and  without  change  of  the  reaction  of  the  mixture, 
occurs  when  the  medium   is    neutral  or  weakly  acid.     The 


THE   FUNCTIONAL    SIGNS.  121 

ferment  coagulum  contracts  on  standing,  and  separates  the 
whey,  which  contains  the  ferments,  and  can  produce  coagula- 
tion in  a  fresh  specimen.  The  most  favorable  temperature 
for  the  action  of  the  ferment  is  between  33°  C.  and  44°  C, 
but  in  the  presence  of  chlorid  of  calcium  it  may  take  place 
at  20°  C.  A  temperature  of  70°  C.  destroys  the  ferment,  but 
not  the  mother  substance.  Boiled  milk  is  coagulated  more 
slowly  than  uncooked  milk. 

The  Qualitative  Tests. — To  five  c.c.  of  sweet  milk  (Leo),  three 
or  four  drops  of  the  unfiltered  and  unneutralized  gastric  con- 
tents are  added,  and  the  covered  glass  is  placed  in  the  ther- 
mostat at  blood-heat.  If  the  labferment  is  present,  the  co- 
agulation occurs  in  ten  or  fifteen  minutes.  A  negative  result 
with  this  method,  on  account  of  the  very  small  quantity  of 
the  gastric  contents  used,  should  not  be  considered  conclu- 
sive. In  the  short  interval,  coagulation  by  micro-organisms 
is  hardly  possible.     But  the  following  test  is  more  conclusive  : 

Five  c.c.  of  the  filtered  contents  are  exactly  neutralized  by 
the  decinormal  alkaline  solution,  always  at  hand,  and  added 
to  an  equal  quantity  of  sweet  neutral,  or  amphoteric  milk. 
The  glass  is  then  placed  in  the  thermostat  at  blood  tempera- 
ture. In  from  five  to  twenty  minutes  coagulation  will  demon- 
strate the  presence  of  the  labferment. 

The  qualitative  test  for  labzymogen  requires  a  special 
preparation  of  the  gastric  contents.  Five  c.c.  of  the  filtered 
contents  are  made  very  slightly  alkaline  with  a  one  per  cent, 
solution  of  sodium  carbonate,  or  with  the  decinormal  alkaline 
solution  and  about  two  c.c.  of  a  one  per  cent,  solution  of  cal- 
cium chlorid  are  added  to  it.  This  is  next  mixed  with  an  equal 
quantity  of  sweet  milk,  and  placed  in  the  thermostat.  The 
alkalinization  has  destroyed  the  ferment,  and  the  calcium 
chlorid  will  convert  the  labzymogen,  if  present,  into  labfer- 
ment, and  the  coagulation  will  take  place  in  the  usual  time. 

The  Quantitative  Tests. — The  quantitative  estimation  of  the 
labsecretion  is  roughly  done  by  dilution,  an  excellent  clinical 
method,  given  by  Boas.  If  the  qualitative  test  for  the  labfer- 
ment has  been  positive,  we  exactly  neutralize  the  filtered 
contents,  and  make  four  dilutions  with  distilled  water  :  i  :  10, 
I  :  20.  I  :  30,  and  i  :  40.  To  five  c.c.  of  each  of  the  dilutions 
we  add  five  c.c.  of  milk,  place  all  in  the  thermostat,  and  note 
the  weakest  dilution  in  which  the  ^agulation  occurs. 

For  the  quantitative  estimation  of  the  labzymogen,  the 
neutralized  contents  are  made  slightly  alkaline,  and  dilutions 
prepared  of  i  :  10,  i  :  20,  i  :  40,  i  :  80,  and  i  :  160.  To  five  c.c. 
of  each   add  two   c.c.  of  the   one  per  cent,   calcium   chlorid 


122  DISEASES  OF  THE  STOMACH. 

solution,  and  five  c.c.  of  milk,  and  place  all  in  the  thermostat, 
and  mark  the  weakest  dilution  in  which  the  coagulation 
occurs. 

Normally,  the  end  dilutions  i :  40  (labferment)  and  1:160 
(labzymogen)  should  give  a  positive  result. 

If  the  gastric  contents  contain  no  free  acid,  before  basing  a 
conclusion  on  a  negative  result  we  should  introduce — and 
withdraw  half  an  hour  later — a  glass  of  -^^J  normal  MCI  in  the 
morning,  when  the  stomach  is  empty.  When  there  is  no 
free  hydrochloric  acid  in  the  contents,  this  method  is  abso- 
lutely necessary,  in  order  to  confirm  or  control  a  negative 
result  after  a  test-meal. 

If  the  gastric  contents  be  neutral,  labferment  is  absent,  but 
labzymogen  may  be  present  exen  in  normal  quantity. 

The  Practical  Value  of  the  Labferment  Signs. — Practically,  we 
may  find  three  conditions:  the  labsecretion  may  be  normal, 
variable,  or  persistently  diminished. 

1.  The  constant  presence,  after  a  test-breakfast,  of  the  lab- 
ferment and  its  mother  substance  in  normal  quantity,  does 
not  always  exclude  an  anatomical  disease.  Rut  in  a  very 
large  majority  of  cases  this  sign  speaks  distinctly  in  favor  of 
a  dynamic  affection,  and  this  rule  is  without  exception  when 
the  acid  secretion  and  the  motor  function  are  also  normal. 
But  in  continuous  excessive  HCl  secretion,  due  to  glandular 
gastritis,  the  test-meal  contents  show  usually  an  increase  of 
labsecretion,  and  labferment  is  often  present  in  greater  quan- 
tity than  labzymogen.  In  gastritis,  associated  with  excessive 
HCl  secretion,  the  labferment  is  above  normal,  although  the 
quantity  of  labzymogen  in  the  contents  removed  at  the  end 
of  one  hour  may  be  diminished.  If  the  contents  be  removed 
sooner,  the  quantity  of  mother  substance  will  be  found  at 
least  equal  to  that  of  health,  and  the  quantity  of  the  con- 
verted ferment  is  usually  normal  or  above  normal  through- 
out the  evolution  of  digestion.  The  rule  which  claims  that 
a  normal  milk-curdling  power  of  the  gastric  contents  excludes 
all  but  the  dynamic  affections  does  not  obtain  in  many  cases 
of  glandular  gastritis,  of  ulcer,  and  of  complicated  myasthenia. 

2.  A  variable  labsecretion  is  a  common  sign  of  incipient 
and  mixed  forms  of  gastritis,  or  of  myasthenia  and  obstruc- 
tive stagnation  or  retention.  The  quantity  varies  because 
the  interstitial  inflammation  varies,  and  because  the  evacua- 
tion of  the  contents  of  the  stomach  is  irregular. 

3.  The  labsecretion  may  be  persistently  diminished.  If 
this  sign  be  established — and  ouk  conclusions  should  not  rest 
on  a  single  examination — there  is  glandular  disease,  and  the 


THE   FUNCTIONAL    SIGNS.  I  23 

degree  of  deficiency  indicates  the  degree  and  diffusion  of 
the  gastritis,  or  it  indicates  glandular  degeneration.  Conse- 
quently, the  functional  sign  may  make  the  exact  diagnosis 
indicate  the  prognosis,  and  dominate  the  treatment. 

{b)  Pepsin  and  Pepsinogen. — Pepsinogen,  the  mother  sub- 
stance of  pepsin,  is  formed  continuously  and,  in  all  proba- 
bility, by  the  chief  cells  of  the  gastric  glands,  and  is  stored 
in  these  cells  to  be  poured  out  under  the  influence  of  diges- 
tive stimulation.  The  chief  cells  are  at  once  the  factory  and 
the  storehouse  of  pepsinogen,  which,  when  given  out  as  one 
of  the  elements  of  the  specific  secretion,  comes  in  contact 
with  the  hydrochloric  acid  or  the  secreted  chlorids,  and  is 
rapidly  converted  into  the  active  pepsin.  The  quantity  of 
pepsinogen  converted  is  conditioned  by  the  percentage  of 
free  hydrochloric  acid,  about  2.5  parts  a  looo  being  the 
most  favorable  strength.  The  organic  acids  also  possess  this 
power  of  conversion. 

In  the  contents  after  a  test-meal,  the  presence  of  pepsin  is 
demonstrated  by  a  positive  biuret  reaction.  But  the  exist- 
ence of  pepsin-hydrochloric  acid  products  is  no  proof  of  the 
secretion  of  pepsinogen  in  sufificient  quantity,  although  the 
sufficiency  of  this  secretion  is  suggested  by  the  disintegra- 
tion and  solution  of  the  bread  and  meat;  but  acid  and  water 
may  accomplish  this  solution  without  the  aid  of  pepsin. 
Consequently,  not  only  when  there  is  no  free  HCl  in  the 
contents,  but  also  when  this  acid  is  present  in  normal  or 
in  excessive  quantity,  the  quantitative  estimation  of  pepsin 
should  be  made  by  testing  the  power  of  the  properly  acidu- 
lated filtrate  to  convert  the  normal  quantity  of  albumin  into 
albumoses  within  the  proper  time.  The  following  methods 
have  been  used  : 

Method  of  Schiff  (1868). — Brucke(i859)  added  to  the  gastric 
contents  a  small  piece  of  hard-boiled  white  of  Q^^,  or  of 
fibrin,  and  made  the  digestive  power  proportionate  to  the 
rapidity  of  the  solution  of  the  fibrin  or  the  white  of  ^%^. 
Schiff  estimated  the  quantity  of  albumin  or  fibrin  dissolved 
in  Briicke's  experiment,  after  the  lapse  of  a  certain  interval, 
by  the  increase  in  specific  gravity.  The  specific  gravity  of 
the  fluid  before  and  after  the  artificial  digestion  is  taken,  and 
from  the  difference  the  quantity  of  substance  dissolved  is 
aclculated. 

Method  of  Qriitzner  (1874). — Griitzner  stained  a  mass  of  fibrin 
with  ammonia-carmin  for  twenty-four  hours,  washed  thor- 
oughly with  water,  and  poured  over  it  a  0.2  per  cent,  solution 
of  HCl.      One-half  gm.    of   the   stained    fibrin,  in    flakes,   is 


124  DISEASES  OF  THE   STOMACH. 

placed   in   the   digestive    solution,    and    the  coloration,  after 
various  intervals,  is  compared  with  a  standard  carmin  scale. 

Method  of  Leube. — Two  tests  are  made,  the  one  with  the 
gastric  contents  alone,  and  the  other  after  the  addition  of 
pepsin.  If  the  latter  dissolves  an  equal  quantity  of  albumin 
more  rapidly  than  the  former,  the  pepsin  is  deficient.  Boas 
compares  the  rapidity  of  the  solution  of  albumin  by  the  gas- 
tric contents  to  be  tested  with  the  rapidity  of  the  solution  of 
the  same  quantity  of  albumin  by  the  normal  contents. 

Method  of  Jaworski  (1887). — Twenty-five  c.c.  of  the  clear  or 
filtered  gastric  contents  are  divided  into  two  equal  parts, 
which  are  placed  in  separate  glasses.  To  one,  a  drop  of  con- 
centrated officinal  HCl  is  added.  A  piece  of  hard-boiled 
white  of  &<g^  (1.5  mm.  thick,  ten  mm.  in  diameter,  and  weigh- 
ing six  centigrams)  is  placed  in  each  glass.  The  two  pre- 
parations are  put  into  the  thermostat  at  40°  C,  the  time 
is  noted  when  the  &oa  cylinders  are  dissolved,  and  the  solu- 
tion is  then  tested  for  peptone.  Three  c.c.  of  a  five  per  cent, 
solution  of  KOH  are  added,  and  into  the  strongly  alkaline 
solution  a  one  per  cent,  solution  of  CUSO4  is  let  fall,  drop  by 
drop,  out  of  the  buret.  The  solution  of  copper  is  added  until  the 
reddish  coloration  is  no  longer  increased  thereby.  The  greater 
the  quantity  of  peptone,  the  later  the  peptone  reaction  begins 
and  the  later  it  reaches  its  greatest  intensity.  The  quantity 
of  peptone  present  is  indicated  by  the  intensity  of  the  color  : 
Hardly  perceptible  pale  rose,  mere  trace  ;  rose,  trace  ;  reddish, 
plain  trace ;  red,  moderate  quantity ;  and  dark  red,  large 
quantity.  Syntonin  and  propeptones  do  not  interfere  with 
the  reaction. 

If,  after  twenty-four  hours,  the  egg  cylinders  have  not 
disappeared  and  the  peptone  reaction  is  negative,  the  test 
specimen  possesses  no  digestive  power.  Normally  acidulated 
specimens  of  the  gastric  contents,  obtained  at  the  height  of 
gastric  digestion,  completely  dissolve  the  qs^^  cylinder  within 
one  hour. 

Method  of  Hammerschlag  ( 1894). — Three  gm.  of  commercial 
egg-albumin  are  dissolved  in  150  c.c.  of  a  solution  containing 
four  parts  of  HCl  per  looo.  The  solution,  after  standing 
twenty-four  hours,  is  filtered,  and  the  filtrate  contains  about 
one  per  cent,  of  albumin.  With  this  preparation  three  tests 
are  made. 

Ten  c.c.  of  the  acid  albumin  solution  are  mi.xed  with  five 
c.c.  of  the  gastric  contents,  and  an  Esbach  tube,  a,  is  filled  to 
the  mark  U  with  the  mixture. 

To  another  ten  c.c.  of  the  preparati<Mi  five   c.c.   of  distilled 


THE   FUNCTIONAL    SIGNS.  1 25 

water  are  added,  and  with  this  a  second  Esbach  tube,  b,  is 
filled  to  the  mark  U. 

A  third  tube,  c,  is  filled  to  the  mark  U  with  a  mixture  con- 
sisting of  ten  c.c.  acid  albumin  solution,  five  c.c.  gastric  con- 
tents, and  0.5  gm.  pepsin. 

All  the  tubes  are  placed  in  the  thermostat  at  37°  C.  for  one 
hour,  removed,  and  filled  to  the  mark  R  with  Esbach's  reagent. 

After  standing  twenty-four  hours  the  quantity  of  sediment 
is  read,  and  the  diminution  of  the  sediment  in  the  tubes  rt  and 
c  is  compared  with  the  sediment  in  the  tube  b.  The  peptoni- 
zation is  represented  by  the  unprecipitated  albumin  products. 
If,  for  example,  tube  a  contains  three  per  cent,  precipitated 
albumin  and  the  control  tube  b  contains  six  per  cent.,  the 
digestive  work  is  50  per  cent. 

Method  of  Klug  (1895). — Tube  peptonization,  according  to 
this  writer,  is  most  active  in  a  preparation  containing  0.5  per 
cent,  to  0.6  per  cent,  free  HCl  and  o.  i  per  cent,  pepsin.  A 
greater  or  less  percentage  than  o.  i  per  cent,  pepsin  diminishes 
peptonization. 

The  test  may  be  made  in  the  following  manner:  Twenty- 
five  c.c.  of  the  filtered  contents,  in  order  to  eliminate  the 
influence  of  the  hydrochloric  acidity,  are  brought  to  a  free 
HCl  acidity  of  0.5  per  cent.  To  this  acidulated  specimen  are 
added  ten  gm.  of  finely  divided  hard-boiled  white  of  egg,  and 
the  mixture  is  placed  in  the  thermostat  at  40^  C.  for  twenty- 
four  hours.  After  this  period  no  more  of  the  &^^  is  utilized, 
and  the  further  process  consists  in  the  transformation  of  the 
syntonin  and  albumoses  into  peptones. 

For  the  differential  estimation  of  the  quantity  of  synto- 
nin, albumoses,  and  peptones  in  the  test  mixture,  Klug  uses 
the  biuret  reaction,  the  intensity  of  which  is  measured  by  the 
spectrophotometer  of  Glan.  The  color  extinction  coefficient 
is  obtained  in  the  usual  manner,  that  part  of  the  spectrum 
between  D  75  E  and  D  100  E  being  used. 

The  digestive  mixture  is  boiled  and  filtered  ;  the  filtrate 
contains  all  the  utilized  albumin.  To  ten  c.c.  of  this  filtrate 
add  five  c.c.  of  a  concentrated  solution  of  caustic  soda  and  six 
drops  of  a  ten  per  cent,  solution  of  cupric  sulphate;  shake 
and  carefully  filter  to  remove  the  excess  of  CUSO4.  The 
coefficient  is  then  taken  (E). 

The  remainder  of  the  filtrate  is  exactly  neutralized  with  a 
solution  of  caustic  soda  and  filtered.  The  syntonin  is  thus 
removed:  Ten  c.c.  of  the  filtrate  are  treated  as  before  and  the 
coefficient  taken  (E^).  Ten  c.c.  of  the  syntonin-free  filtrate 
are  next  boiled  with  an  excess  of  pure  sulphate  of  ammonium 


126  DISEASES  OF  THE  STOMACH. 

and  filtered  after  cooling.  The  albumoses,  except  possibly 
dciitero-albuniose,  are  thus  removed :  To  one  c.c.  of  the 
filtrate  free  from  albumoses  are  added  five  c.c.  of  concentrated 
solution  of  NaOH  and  three  drops  of  the  ten  per  cent,  solution 
of  CUSO4.  Filter  repeatedly  before  taking  the  coefficient 
(£3).  E2  —  £3  =  albumoses.  E^  —  E^  =  syntonin.  £=^ 
=  peptones. 

Method  of  Oppler  (1896). — Oppler's  method  is  correct  in 
principle,  but  it  is  long  and  tedious  in  practice.  It  is  the  best 
research  method,  but  the  method  of  Hammerschlag  is  suffi- 
ciently accurate  for  clinical  purposes. 

A  neutral  two  per  cent,  solution  of  egg-albumin,  preserved 
by  the  addition  of  5  :  1000  chloroform,  is  mixed  in  definite 
proportion  with  a  dilution  of  the  gastric  filtrate  of  a  definite 
HCl  (77,  or  0.281  per  cent.)  acidity  and  placed  in  the  ther- 
mostat for  three  hours.  The  quantity  of  nitrogen — and  conse- 
quently of  albumin — is  estimated  in  the  solution  of  dried  egg- 
albumin,  in  the  diluted  contents  filtrate,  and  in  the  mixture 
(placed  three  hours  in  the  thermostat  at  37.5°  C.)  after  the 
removal  of  the  undigested  albumin.  According  to  Oppler's 
investigations,  50  c.c.  of  the  total  (one  hour  after  the  test- 
breakfast)  ga.stric  contents,  after  dilution  to  the  following 
quantities,  digests  during  three  hours  the  following  percent- 
ages of  the  albumin  in  20  c.c.  of  the  two  per  cent,  solution 
of  commercial  egg-albumin. 

Wlien    diluted  to    I   liter,  about  70  per  cent. 

"         "       2      "  "         67      "  " 

"  "         "       5       "  "        60      "  " 

"  "         "    10      "  "        50      " 

"  "       "  20    "        "      45     "       " 

A  I  :  1000  solution  of  pepsin  (pepsin,  one;  acid  hydro- 
chloric, 20;  aq.,  1000)  digests  in  three  hours  about  35  per 
cent,  of  the  albumin  in  the  solution. 

The  test  of  digestive  power  is  made  in  the  following  man- 
ner:  The  £wald-Boas  test-breakfast  is  given  on  an  empty 
stomach,  and  one  hour  later  the  contents  are  removed  ;  the 
stomach  is  washed  with  repeated  small  quantities  of  distilled 
water  until  the  return  fluid  is  clear  and  the  mixed  wash-water 
and  expressed  contents  arc  diluted  to  one  liter  (or  two)  and 
brought  to  an  acidity  of  ^J  (0.28 1  per  cent.)  by  the  addition 
of  dilute  HCl.  Fifty  c.c.  of  this  acidulated  dilution  are  mixed 
with  20  c.c.  of  the  two  per  cent,  solution  of  egg-albumin,  and 
the  mixture  is  placed  in  the  thermostat  at  37.5°  C.  for  three 
hours.  The  mixture  is  removed  from  the  thermostat,  exactly 
neutralized   by  the   addition   (quantity   necessary  being   pre- 


THE   FUNCTIONAL    SIGNS.  12 J 

vioLi.sly  determined)  of  NaOH,  boiled,  acidified  with  acetic 
acid,  five  c.c.  saturated  solution  of  NaCl  are  added,  and  the 
mixture  is  again  boiled,  washed  with  enough  distilled  water 
to  make  1 50  c.c,  and  filtered  after  it  has  become  cool.  (Oppler 
makes  a  control  test  at  the  same  time.)  The  quantity  of 
n-itrogen  is  estimated  in  50  c.c.  of  the  filtrate  by  the  Kjeldal 
method,  and  the  result  is  multiplied  by  three.  The  quantity 
of  nitrogen  in  the  dilution  of  the  contents — and  in  the  H2SO4 
used  as  a  reagent — is  deducted.  The  remainder  is  the  quantity 
of  digested  albumin.  If,  for  example,  the  solution  of  egg- 
albumin  contains  2.1  per  cent,  albumin,  and  50  c.c.  of  the 
diluted  (one  liter)  total  gastric  contents  contain  77.5  milli- 
grams of  N,  and  the  50  c.c.  of  the  test  digestion  filtrate  contain 
22.4  milligrams  of  N,  then  22.4  X  3,  or  67.2  milligrams  of  N 
have  been  digested.  Of  this  quantity  17.5  milligrams  are 
already  present  in  the  gastric  contents.  Consequently,  the 
remainder,  after  this  is  subtracted,  when  multiplied  by  5 
(20  c.c.  being  used),  is  equal  to  the  quantity  of  the  albumin 
in  100  c.c.  of  the  test  albumin  solution  which  has  been 
digested.  The  248.5  milligrams  of  N  are  equal  to  1.55  gr. 
of  albumin,  which  is  74  per  cent,  of  2.1.  That  is,  the  digestive 
power  is  a  little  greater  than  normal  (70  per  cent.),  or  a  little 
more  than  twice  as  great  as  the  digestive  power  (3.5  per  cent.) 
of  the  I  :  1000  solution  of  pepsin. 

The  Practical  Value  of  the  Pepsin  Signs. — Pepsin  may  be 
formed  in  normal,  in  excessive,  or  in  subnormal  quantity. 
A  continuous  normal  pepsinogen  secretion  is  a  good  sign  of 
the  integrity  of  the  glandular  layer;  but  a  mild  anatomical 
disease  of  the  stomach  may  be  present  without  causing  a 
noteworthy  change  in  the  quantity  of  pepsin. 

Pepsin,  contrary  to  the  common  belief,  may  be  secreted  in 
excessive  quantity.  This  excessive  secretion  is  often  met 
with  in  chronic  hypersthenic  (glandular)  gastritis.  The  early 
morning  contents  of  continuous  secretion  often  digest  more 
rapidly  than  the  contents  obtained  after  a  test-meal  given  to 
the  same  individual.  The  fluid  of  gastric  retention  with  free 
HCl  usually  digests  better  when  diluted  and  acidulated  with 
HCl.  But  if  the  irritation  and  continuous  secretion  and  the 
accumulation  of  ferments  be  controlled  for  a  few  days  by 
diet  and  lavage,  the  actual  diminished  power  of  secretion  may 
be  made  clear  in  some  cases  of  gastric  retention.  Conse- 
quently an  excess  of  pepsin  may  be  due  to  the  secretion  of  a 
ga.stric  juice  which  is  excessively  rich  in  it  or  to  its  accumu- 
lation in  the  stomach.  In  both  instances  the  tests  of  Ham- 
merschlag  and  Oppler   give  an   increase   of  digestive  power. 


128  DISEASES  OF  THE  STOMACH. 

and  the  dilutions  likewise  digest  more  albumin  than  do  simi- 
lar dilutions  of  the  test-breakfast  contents.  Whenever  the 
filtrate  of  the  early  morning  contents  possesses  greater  diges- 
tive power  than  the  filtrate  of  the  test-breakfast  contents, 
there  is  motor  insufficiency.  In  simple  continuous  secretion, 
the  early  morning  contents  possess  no  greater  digestive 
power  than  the  contents  after  the  test-breakfast,  and  the 
specific  gravity  is  that  of  the  gastric  juice — 1004  to  1006. 

In  still  another  condition  the  pepsin  tests  are  valuable,  as 
when  there  is  persistent  and  progressive  diminution  of  the 
specific  elements  of  secretion.  This  is  a  physical  sign  of 
chronic  asthenic  gastritis,  of  atrophy  of  the  gastric  glands, 
or  of  carcinoma.  But  pepsin  secretion  is  commonly  dimin- 
ished in  chronic  inanition,  and  variations  of  quantity  occur  in 
consequence  of  nervous  influences,  particularly  in  hysteria 
and  in  adenasthenia  gastrica.  Consequently,  not  even  a  great 
diminution  of  the  secretion  of  this  ferment  should  be  consid- 
ered pathognomonic  of  severe  glandular  disease  without 
other  corroborative  signs.  The  diminution  of  pepsin  is  not 
characteristic  of  any  particular  disease  of  the  stomach,  and 
its  quantity  varies  in  very  close  relation  with  the  quantity  of 
total  HCl.  Consequently,  its  increase  or  decrease  or  its 
presence  in  normal  quantity  in  the  contents  after  the  test- 
breakfast  possesses  about  the  same  significance  as  like  states 
of  HCl  secretion.  But  there  is  no  doubt  that  the  diminution 
and  the  loss  of  labferment  secretion  are  very  grave  signs  and 
are  much  less  frequent  than  the  diminution  and  loss  of  hydro- 
chloric acid  and  pepsin  secretion. 

3.  Mucus,  OR  THE  General  secretion. 

The  general  secretion  of  the  stomach  is  mucus,  a  product 
of  the  cylindrical  cells  which  thickly  line  the  surface  and 
extend  a  short  distance  into  the  peptic  glands  and  line  com- 
pletely the  mucus  glands.  This  secretion  forms  a  very 
important  protection  to  the  delicate  structures  which  it  nor- 
mally covers  as  a  thin  layer.  In  catarrh,  the  quantity  of  the 
mucus  may  be  greatly  increased,  and  forms,  particularly  about 
the  pylorus,  very  thick  masses,  either  clear  and  tough  with  a 
pale  membrane  beneath  or  tinged  with  blood  and  mixed  with 
the  exudate  from  the  hyperemic  blood-vessels. 

The  mucus  which  is  .secreted  by  the  normal  cylindrical 
surface  c[)ithelium  contains  only  a  trace  of  mucin,  and  no 
cloudiness  is  produced  by  the  addition  to  it  of  either  distilled 
water  (dilution)  or  acetic  acid.     It  is   readily  dissolved  and 


THE   FUNCTIONAL   SIGNS.  1 29 

digested  by  the  gastric  juice.  Consequently,  the  chemical 
test  of  normal  gastric  mucus  is  worthless,  and  the  search  for 
excessive  mucus  secretion  should  be  made,  not  in  the  test- 
meal  contents,  but  in  the  early  morning  wash-water.  In  the 
morning  before  breakfast  3^  of  a  pint  of  water  is  allowed  to 
flow  in  and  out  of  the  stomach  (siphonage)  several  times, 
and  this  wash-water  is  examined  for  mucus.  The  stomach 
mucus  will  then  appear  in  shreds  and  in  flocculent  masses 
mixed  with  a  few  fat  droplets,  starch  granules,  and  cylindrical 
epithelial  cells.  It  stains  but  faintly  with  methj'l-green  and 
thionin,  and  it  swells,  instead  of  coagulating  and  contracting, 
on  the  addition  of  acetic  acid.  The  gastric  mucus,  however, 
which  is  formed  after  the  transformation  of  the  cylindrical 
into  goblet  cells  (gastritis),  contains  more  mucin,  and  conse- 
quently stains  more  intensely  and  precipitates  on  the  addition 
of  acetic  acid.  The  presence  of  much  mucus  in  the  wash- 
water  or  in  the  stomach-contents  delays  filtration,  and  large 
quantities  of  it  may  be  left  on  the  filter.  The  greatest  quan- 
tities of  mucus  are  found  in  asthenic  and  atrophic  gastritis 
and  in  carcinoma.  It  accumulates  because  it  is  secreted  in 
excess,  contains  more  mucin,  and  is  not  dissolved  by  diges- 
tion. The  quantity  of  undissolved  mucus  is  in  inverse 
proportion  to  the  quantity  of  HCl  and  pepsin.  The  per- 
sistent secretion  of  mucus  in  excess  is  a  distinctive  sign  of 
gastritis — be  the  gastritis  primary  or  secondary,  acute  or 
chronic,  asthenic  or  hypersthenic,  or  atrophic. 

The  mucus  removed  from  the  stomach  may  have  been 
swallowed.  The  swallowed  mucus  forms  glairy  lumps,  mixed 
with  squamous  epithelium  and  often  with  pus  cells,  and  it 
frequently  floats  on  the  surface.  The  stomach  mucus  occurs 
in  shreds  or  flocculent  masses,  is  mixed  with  starch  granules, 
contains  cylinder  or  beaker  cells  or  their  nuclei,  and  only  a 
few  leukocytes.  The  collection  of  mucus  in  the  stomach  may 
in  reality  be  an  accumulation  of  saliva.  The  saliva  may  be 
detected  by  the  reaction  of  the  sulphocyanid  of  potassium 
which  it  contains  with  iron.  A  dilute  solution  of  chlorid  of 
iron  is  added,  drop  by  drop,  until  the  red  color  which  is  pro- 
duced no  longer  increases  in  intensity.  The  coloration  re- 
mains after  the  addition  of  hydrochloric  acid  and  is  not  dis- 
charged by  bichlorid  of  mercury,  otherwise  the  red  color  is  not 
produced  by  saliva. 


130  DISEASES  OF  THE  STOMACH. 


2.  THE  MOTOR  FUNCTION. 

The  gastric  muscle  plays  an  exceedingly  important  part  in 
the  pathology  of  the  stomach.  Motor  insufficiency  is  a 
serious  primary  trouble,  and  likewise  a  serious  complica- 
tion. The  cardiac  muscle  has  recently  been  given  its  proper 
place  in  the  pathology  of  the  heart.  For  a  long  period 
attention  was  directed  chiefly  to  the  valves  and  to  the  peri- 
cardium ;  the  heart  muscle  was  neglected.  But  the  involun- 
tary muscular  system  deserves  a  more  prominent  place  in  inter- 
nal pathology.  Attention  has  been  directed  too  exclusively  to 
the  mucous  membrane.  But  the  uterine  muscle  is  no  more 
important  in  labor,  nor  the  heart  muscle  in  the  circulation  of 
the  blood,  than  is  the  gastric  muscle  in  digestion.  The  integ- 
rity of  the  muscle  cells  is  no  less  important  than  that  of  the 
cells  which  secrete. 

When  the  general  strength  and  nutrition  are  affected  in  an 
unfavorable  manner  bj'  a  disease  of  the  stomach,  this  result 
can  usually  be  attributed  to  a  motor  defect,  which,  unlike 
secretory  insufficiency,  can  not  be  compensated.  The  chemi- 
cal work  of  the  stomach  may  be  null  without  affecting  nutri- 
tion if  the  integrity  of  the  motor  function  is  maintained  and 
the  contents  of  the  stomach  are  given  over  to  the  healthy 
intestines  for  digestion  and  assimilation.  The  intestinal 
juices  are  much  more  powerful  and  active  than  the  gastric 
secretion.  This  is  the  teaching  of  operations  on  the  stomach 
which  simply  secure  the  passage  of  the  food  into  the  intestines  ; 
such  is  also  the  teaching  of  experiments  on  animals  and  of 
pathology. 

The  movements  of  the  stomach  are  two — the  evacuating 
and  the  churning.  The  movements  are  in  all  probability  due 
to  the  excitation  of  the  ganglia  in  its  walls,  through  which 
the  vagosympathetic  branches  which  go  to  the  stomach 
probably  also  exert  their  influence.  The  stimulant  of  these 
movements  is  not  HCl  only  ;  the  movements  continue  when 
the  reaction  is  neutral,  but  are  excited  by  the  various  elements 
of  the  contents. 

The  movements  of  the  stomach  during  digestion  and  the 
process  by  which  the  organ  empties  itself  have  long  been 
the  subject  of  careful  study.  The  character  of  these  move- 
ments is  no  less  a  matter  of  controversy  than  is  their  explana- 
tion. The  philosophy  of  the  subject  may  be  left  out  of  account 
in  a  clinical  work  and  only  the  results  of  observations  need 
be  fjathered. 


THE   FUNCTIONAL    SIGNS.  I3I 

Viewed  from  the  results,  the  contraction  of  the  muscular 
layer  of  the  stomach  produces  a  twofold  effect — the  increase  of 
intragastric  pressure  and  the  motion  of  the  contents.  The  iibers 
the  contraction  of  which  causes  these  results  may  act  con- 
temporaneously and  in  union  or  separately  and  independently. 

During  the  first  period  of  digestion,  the  duration  of  which 
is  dependent  upon  the  physiological  action  of  the  food,  the 
tonic  contraction  predominates,  and  the  motionless  gastric 
wall  applies  itself  closely  to  the  gastric  contents.  This  period 
of  high  intragastric  pressure  may  last  a  few  minutes  or  two 
or  three  hours,  the  duration  being  determined  by  the  physical 
and  chemical  qualities  and  the  physiological  action  of  the 
contents  and  by  the  power  of  those  fibers  which  have  to  do 
with  the  result. 

The  second  period  is  that  of  the  worm-like  movements, 
which  are  cardiac,  pyloric,  or  total,  according  to  the  location 
and  extent  of  their  visible  expression. 

The  movements  of  the  cardiac  portion  begin  at  the  cardia, 
are  slow  and  weak,  and  lose  themselves  in  the  middle  of  the 
organ.  These  peristaltic  movements  may  be  contempora- 
neous with  those  of  the  pylorus  or  they  may  be  alternating. 
Observation  has  established  between  them  no  law. 

The  movements  of  the  pyloric  end  are  more  complex. 
Two  forms  have  been  observed  and  may  be  accepted  as 
physiological :  First,  those  which  begin  on  the  cardiac  side 
of  the  pylorus  and  become  stronger  as  they  pass  forward  and 
disappear  in  the  duodenum  ;  second,  those  which  begin  on 
the  descending  portion  of  the  duodenum  and  move  backward 
on  to  the  stomach,  in  the  middle  third  of  which  they  are 
lost,  soon  to  reappear  with  greater  power  along  the  pylorus 
to  the  duodenum.  The  character  of  these  movements  forms 
the  basis  of  a  theory  which  maintains  that  the  opening  of 
the  pylorus  is  due  to  a  cause  which  has  its  origin  in  the 
duodenum. 

The  total  movements  are  exclusively  peristaltic,  and  begin 
at  the  cardia  and  move  slowly  toward  the  pylorus,  near  which 
the  wave  becomes  higher  and  more  rapid.  The  effect  of  the 
peristalsis  is  more  visible  along  the  greater  curvature,  the 
thick  longitudinal  bundle  along  the  lesser  curvature  serving 
as  the  fixed  line  of  attachment.  These  lesser  curvature 
longitudinal  fibers  extend  to  the  duodenum,  over  the  upper 
and  anterior  surfaces  of  which  they  spread.  Their  con- 
traction would  tend  to  straighten  the  line  between  the  cardia 
and  the  more  immovable  duodenum,  and,  if  not  counteracted 
by  contraction  of  the  ring  fibers,  it  would  open  the  pylorus. 


132  DISEASES  OF  THE  STOMACH. 

The  excitation  of  the  splanchnic  in  the  thorax,  according 
to  Oser,  opens  tlie  p}'lorus  and  stops  its  rhythmic  contrac- 
tions. Oppenheinier  explains  this  result  by  the  contractions 
of  the  intestinal  arterioles  and  by  intestinal  contraction  on 
account  of  the  consequent  anemia.  Such  an  anemic  condi- 
tion is  present  when  the  intestines  are  enipty  and  at  rest. 
The  intestines  become  shortened  in  inanition,  and  all  condi- 
tions that  increase  absorption  and  nutritive  change  also  cause 
the  stomach  to  empty  itself  more  rapidly.  Such  is  likewise 
the  effect  of  purgatives  which  act  on  the  intestines.  This 
would  suggest  the  possibility  of  the  opening  of  the  pylorus 
through  the  contraction  of  the  longitudinal  fibers  of  the 
duodenum  extending  on  to  the  stomach. 

The  movements  of  the  stomach  are  excited  and  controlled 
by  the  ganglia  in  its  walls;  these  ganglia  are  brought  into 
activity  by  the  properties  of  the  gastric  contents  and  by  the 
impression  received  through  the  vagosympathetic  nerves. 
Particular  centers  or  areas  in  the  central  nervous  system  are 
connected  with  the  gastric  muscle.  The  vomiting  center  is 
the  same  as  that  of  respiration  (Grimm);  or,  according  to 
Thomas,  is  a  single  center  in  the  posterior  part  of  the  medulla 
oblongata,  beginning  two  mm.  before  and  ending  three  mm. 
behind  the  calamus  scriptorius.  The  centers  for  the  contrac- 
tion of  the  cardia  are  located  in  the  corpora  quadrigemina, 
the  fibers  from  which  run  partly  in  the  cord  (to  the  eighth 
cervical  vertebra,  and  thence  to  the  stomach  in  the  splanchnics) 
and  partly  in  the  vagi  :  the  centers  for  the  movements  of  the 
wall  are  in  the  same  bodies,  but  the  fibers  run  exclusively  in 
the  cord  and  the  thoracic  sympathetic  (Openchowski,  Hlasko). 
The  dilator  centers  of  the  cardia  are  situated  near  the  an- 
terior commissure  in  the  vicinity  of  the  union  of  the  nucleus 
caudatus  and  nucleus  lentiformis :  the  fibers  from  these 
centers  run  in  the  cord  to  the  fifth  cervical  vertebra  and  also 
in  the  vagi  (Knaut)  on  their  way  to  the  cardia. 

The  normal  motor  function  is  dependent  on  a  j^roper  nerve 
supply,  on  a  healthy  muscle,  and  on  a  physiological  excita- 
tion. Consequently,  the  motor  function  may  be  deranged 
through  the  central  and  sympathetic  nerves,  by  a  badly  nour- 
ished, weak,  or  diseased  gastric  muscle,  and  by  improper  con- 
tents in  the  stomach.  The  muscle  may  be  hindered  in  its 
work  by  adhesions,  deformities,  displacements,  and  obstruc- 
tion to  the  evacuation  of  the  stomach.  Several  methods 
have  been  given  for  testing  the  motor  function. 

Some  valuable  information  concerning  the  motor  function 
may  be  obtained  from  the  quantity  of  the  contents  after  a 


THE   FUNCTIONAL    SIGNS.  1 33 

meal  given  to  test  the  secretory  activity  of  the  stomach. 
Normally,  the  total  quantity  of  the  contents  of  the  stomach 
after  the  test-breakfast  is  about  125  c.c. ;  after  the  test-meal  of 
See,  about  175  c.c.  ;  and  after  the  test-dinner  of  Riegel,  about 
200  c.c.  If  these  values  are  increased  more  than  25  c.c,  there 
is  motor  insufficiency;  or  if  they  are  decreased  more  than  25 
c.c,  the  evacuation  of  the  stomach  is  too  rapid — provided  the 
increase  or  decrease  is  not  produced  by  supersecretion  or  sub- 
secretion  respectively.  The  total  quantity  of  the  contents 
must  be  estimated  by  the  method  of  Mathieu  and  Remond 
or  by  the  method  of  Strauss. 

The  method  of  Mathieu  and  Remond  is  based  on  the  prin- 
ciple that  the  acidity  of  the  contents  before  removal  from  the 
stomach  is  equally  diffused.  Enough  of  the  contents  is  first 
removed  by  expression  for  analysis,  and  the  vessel  containing 
it  is  set  aside.  Two  hundred  c.c.  of  distilled  water  (or  a 
particular  quantity)  are  next  introduced  into  the  stomach 
through  the  tube  and  well  mixed  with  the  contents  by  alter- 
nately lowering  and  raising  the  funnel  so  as  to  allow  the 
mi.xture  to  flow  back  and  forth  between  the  stomach  and  the 
funnel.  The  diluted  contents  are  then  removed  by  expres- 
sion and  received  in  a  special  vessel.  The  quantity  of  the 
undiluted  contents  (p)  and  its  total  acidity  are  known.  The 
quantity  of  water  used  (w)  and  the  acidity  of  the  diluted  con- 
tents   (a^)    are    also    known.     Hence:    ax    =    a^w    -f-    a^x 

.-.  X  =  — ^.     The  total  contents  are  consequently  equal  to 

p  -I ^J^-    This  method,  commonly  ascribed  to  Mathieu  and 

a  — a^ 

Remond  (1890),  was  first  published  by  Jaworski  (1882). 
Strauss  estimates  the  total  quantity  from  the  specific  gravities 
of  the  diluted  and  undiluted  contents.  If  x  represents  the 
quantity  left  in  the  stomach  after  the  first  expression,  s  and 
s^  the  specific  gravity  of  the  undiluted  and  diluted  con- 
tents respectively,  and  w  the  quantity  of  distilled  water  used, 

X  —    ^-^-^^-^JlL.     The  total  quantity  is  consequently  equal  to 

p  +  — ^ ^— .     Goldschmidt  employs  only  50  c.c.  of  distilled 

water  for  diluting  the  unexpressed  contents,  and  adds  dis- 
tilled water  to  the  undiluted  contents  until  the  specific  gravity 
is  reduced  to  that  of  the  diluted  contents.  The  quantity  of 
distilled  water  which  is  required  for  this  purpose  represents 
the  quantity  of  contents  left  in  the  stomach  after  the  first 
expression,  which  should  be  as  complete  as  possible. 


134  DISEASES  OF  THE   STOMACH. 

The  bacteriological  as  well  as  the  functional  signs  give 
some  information  concerning  the  motor  work  done  by  the 
stomach,  as  stagnation  and  retention  are  two  of  the  conditions 
favorable  to  germ  development.  But  methods  have  been 
devised  for  testing  the  motor  function  more  directly.  Before 
describing  these  direct  methods  the  ingenious  method  of 
Ewald  and  the  old  plan  of  Chomel  will  be  discussed. 

Method  of  Ewald  and  Sievers  (1887). — The  salol  test  of 
Ewald,  as  this  great  clinician  himself  admits,  is  onl)'  a  very 
crude  one.  Salol  is  insoluble  in  the  normal  gastric  juice,  and 
is  decomposed  in  the  intestine  into  carbolic  and  salicylic  acids. 
The  latter  undergoes  absorption, and  is  eliminated  as  salicyluric 
acid  in  the  urine.  If  about  15  grs.  of  the  salol  be  given  in 
capsules  at  the  height  of  digestion  by  the  normal  stomach,  the 
salicyluric  acid  may  be  detected  in  the  urine  in  about  sixty 
minutes,  sometimes  in  thirty  minutes,  and  sometimes  its  elimi- 
nation begins  in  seventy-five  minutes.  The  longer  the  lapse 
of  time  before  its  appearance  in  the  urine,  the  greater  is  the 
motor  insufficiency. 

The  test  for  the  salicyluric  acid  in  the  urine  is  a  very  simple 
one.  A  few  drops  of  the  urine  are  allowed  to  fall  on  a  piece 
of  filter  paper,  and  three  or  four  drops  of  a  ten  per  cent, 
solution  of  neutral  chlorid  of  iron  are  placed  so  near  the 
edge  of  the  wet  spot  as  to  mingle  with  it.  The  violet  color 
formed  reveals  the  presence  of  salicyluric  acid.  A  mere  trace 
may  be  detected  by  first  strongly  acidulating  a  portion  of  the 
urine  with  HCl  and  testing,  with  the  chlorid  of  iron,  the  resi- 
due of  the  evaporation  of  an  ether  extract. 

Huber  claims  that  the  time  of  disappearance  of  the  sali- 
cylic acid  from  the  urine  is  a  better  measure  of  the  motor 
insufficiency  than  the  moment  when  it  can  be  first  detected. 
In  health,  the  salicylic  acid  should  all  be  eliminated  in  twenty- 
seven  hours,  and  the  persistence  of  the  reaction  beyond  this 
period  is  proportionate  to  the  motor  insufficiency.  This  brings 
in  the  very  uncertain  factors  of  absorption,  elimination,  and 
the  rapidity  of  the  decomposition  of  the  compound  ;  and  clin- 
ically the  liability  to  error  is  greater  than  in  the  simpler  test 
of  Ewald. 

The  saliva  decomposes  salol,  and  this  may  occur  in  the 
stomach  if  it  contain  much  alkaline  mucus  or  exudate.  Bac- 
teria decompose  it  in  the  stomach.  The  myasthenic  or  in- 
completely obstructed  stomach  does  not  empty  itself  all  at 
once,  and  at  a  particular  moment,  but  intermittently  through- 
out the  period  of  digestion,  either  too  slowly  (stagnation)  or 
never  completely  (retention).     These  facts  would  suggest  the 


THE  FUNCTIONAL   SIGNS.  I  35 

fallacies  of  the  method.  But  theoretical  considerations  are 
of  little  value  when  the  practical  test  can  be  made.  The 
application  of  the  method  at  the  bedside  reveals  the  very 
limited  value  of  the  test  and  the  inconstancy  of  the  results. 
The  necessity  of  urinating  every  ten  minutes  until  the  salicyl- 
uric acid  appears  in  the  urine  renders  the  method  inconvenient 
for  men  and  impracticable  for  women.  Fleischer  gives  a 
grain  and  a  half  of  iodoform  at  the  beginning  of  a  meal,  and 
notes  the  moment  of  the  appearance  of  iodin  in  the  saliva. 
The  information  obtained  through  the  salol  and  iodoform  tests 
is  comparatively  insignificant. 

Method  of  Chomel. — The  splashing  sounds  give  some  in- 
formation concerning  the  state  of  the  gastric  muscle  during 
digestion,  and  concerning  the  time  which  the  stomach  re- 
quires for  the  complete  evacuation  of  its  contents.  A  strong 
and  healthy  stomach  splashes  but  little  or  intermittently,  or 
it  does  not  splash  at  all  during  the  digestion  of  an  ordinary 
meal.  Splashing  throughout  the  period  of  digestion  and  which 
is  demonstrable  from  day  to  day,  is  a  sign  that  the  stomach 
muscle  does  not  properly  contract  on  its  contents  and  per- 
form its  churning  work.  This  test  of  the  tonicity  of  the 
muscle  may  be  made  during  digestion,  or  after  the  ad- 
ministration of  a  glass  of  cold  water  during  the  period  of 
functional  repose.  The  splashing  sounds  are  also  used  to 
test  the  evacuating  power  of  the  stomach.  Splashing  can 
not  be  produced  when  the  stomach  is  empty,  and  it  always 
denotes  that  the  stomach  contains  fluid  and  gas.  If  splashing 
can  be  elicited  when  the  stomach  should  contain  none 
of  the  previous  meal,  the  evacuation  of  the  stomach  is  de- 
layed. If  it  can  be  produced  just  before  the  second  and  third 
meals  of  the  day,  stagnation  of  the  second  degree  is  present. 
If  the  splashing  can  be  produced  in  the  morning  before 
breakfast,  it  is  a  sign  of  retention.  The  validity  of  these 
signs  depends  on  two  conditions — namely,  no  fluid  must  be 
swallowed  during  the  period  between  the  end  of  the  meal 
and  the  examination,  and  excessive  or  prolonged  or  continu- 
ous secretion  must  be  excluded.  The  method  of  Chomel  is 
valuable  as  a  rough  preliminary  test. 

Method  of  Leube. — The  method  of  Leube,  with  the  modi- 
fication of  Boas,  is  a  most  excellent  and  complete  test  of  the 
evacuation  sufficiency  of  the  stomach.  The  patient  is  directed 
to  eat  a  plate  of  soup,  one  roll,  and  a  beefsteak.  Seven  hours 
later  the  stomach  should  normally  be  empty.  If  the  stomach 
is  washed  out  at  this  time,  and  a  notable  residue  of  the  meal 
is  obtained,  the  stomach  has   failed  to  evacuate  itself  within 


136  DISEASES  OF  THE   STOMACH. 

the  proper  period.  This  failure  may  be  due  to  myasthenia 
or  to  obstruction,  or  to  both,  or  to  excessive  secretion. 
Leube's  metliod  estabHshes  an  evacuation  insufficiency,  but 
not  tlie  decree  of  it. 

To  determine  the  degree  of  motor  insufficiency.  Boas 
recommends  that  an  evening  meal  consisting  of  two  cups 
of  tea,  two  small  rolls,  and  a  cold  meat  be  given  at  8  o'clock, 
after  thorough  lavage,  unless  the  stomach  is  already  empty 
and  clean.  No  visible  (macroscopic)  remnants  of  this  meal 
should  be  in  the  stomach  on  the  following  morning  before 
breakfast,  unless  motor  insufficienc}'  of  the  second  degree 
(Boas)  exists.  Naturally,  other  meals  than  those  of  Leube 
and  Boas  may  be  given  ;  but  whatever  meal  is  prescribed,  the 
moment  of  its  complete  evacuation  by  the  normal  stomach 
should  be  known,  and  used  as  the  measure  of  motor  suf- 
ficiency. 

In  practice  it  is  best  to  learn  how  the  stomach  conducts 
itself  with  reference  to  the  usual  meals — breakfast,  lunch,  and 
dinner,  or  breakfast,  dinner,  and  supper;  for  in  dietetics  it  is 
categorically  imperative  that  the  stomach  should  be  empty  at 
the  beginning  of  each  meal,  and  we  accordingly  recognize 
three  degrees  of  motor  insufficiency  :  In  mild  stagnation  the 
evacuation  of  the  stomach  is  delayed,  but  the  stomach  empties 
itself  completely  between  each  meal ;  in  severe  stagnation 
the  stomach  is  found  empty  only  in  the  early  morning  before 
breakfast;  in  retention  the  stomach  is  not  empty  at  any 
moment  during  the  twenty-four  hours,  and  in  the  morning 
before  breakfast  it  contains  food  and  digestive  products,  the 
contents  being  more  acid  than  the  contents  removed  at  the 
acme  of  the  digestion  of  a  test-meal,  and  of  a  higher  .specific 
gravity  than  the  gastric  juice  (1004  to  1006).  If  the  stomach 
be  found  empty  before  each  meal,  and  if  the  evacuation  of  the 
stomach  be  delayed,  as  revealed  by  abnormal  splashing,  or  by 
too  large  a  quantity  of  contents  after  the  test-meals,  or  by 
the  pre.sence  of  contents  at  the  moment  after  a  particular 
meal  when  the  stomach  should  be  empty,  there  is  mild  stag- 
nation or  excessive  secretion,  or  possibly  the  two  conditions 
coexist.  If  the  stomach  be  empty  only  in  the  morning  before 
breakfast,  there  is  severe  stagnation  or  prolonged  digestion 
due  to  excessive  secretion,  or  the  two  conditions  may  coexist. 
If  the  stomach  is  not  empty  before  breakfast,  there  is  reten- 
tion or  continuous  secretion,  or  both  conditions  may  be 
present.  The  differentiation  of  excessive  and  continuous 
secretion  from  myasthenic  and  obstructive  stagnation  and 
retention  is  discussed  in  Sections  IV  and  V. 


THE   FUNCTIONAL    SIGNS.  I  37 

But  how  can  it  be  determined  that  the  stomach  is  empty 
before  meals  or  at  a  particular  moment  after  meals  ?  If  the 
stomach  splashes  it  is  not  empty ;  if  contents  can  be  ex- 
pressed or  aspirated,  it  is  not  empty ;  but  when  no 
splashing  can  be  elicited  and  when  no  contents  can  be 
expressed  or  aspirated  the  stomach  may  not  be  empty.  If 
the  tube  be  introduced  into  the  stomach  until  its  tip  touches 
the  greater  curvature,  and  if  air  be  forced  through  the  tube 
by  compressing  an  attached  bulb,  the  ear,  applied  over  the 
stomach,  will  detect  bubbling  when  the  stomach  is  not  empty. 
Or  if  lOO  c.c.  of  a  one  per  cent,  solution  of  sugar  be  intro- 
duced into  the  stomach,  the  percentage  of  sugar  will  be 
diminished  through  dilution  by  the  contents.  The  exact 
quantity  of  the  contents  can  be  estimated  by  dividing  lOO  by 
the  percentage  of  sugar  in  the  expressed  or  aspirated  dilution 
(determined  by  the  ammonia  and  copper  mixture)  and  sub- 
tracting lOO  from  the  result. 

Method  of  Mathieu. — The  method  of  Mathieu  and  Hallot 
is  an  excellent  one.  It  is  a  very  great  modification  of  the  old 
oil  method  of  Klemperer.  A  test-meal  containing  a  certain 
quantity  of  emulsionized  oil  is  given,  the  tube  is  introduced 
after  a  stated  interval,  and  the  contents  are  removed.  The 
entire  quantity  of  oil  in  the  removed  contents  is  estimated. 
The  part  of  the  oil  evacuated  represents  the  motor  work. 

The  test-breakfast,  which  is  eaten  in  the  morning  on  an 
empty  stomach,  has  the  following  composition  :  60  gm.  of 
bread  ;  an  emulsion  of  10  gm.  of  oil  of  sweet  almonds,  5 
gm.  of  powdered  gum  arabic,  30  gm.  of  simple  syrup,  and 
enough  weak  tea  to  make  250  cm.  One  hour  after  the  be- 
ginning of  the  meal  the  contents  are  removed  and  the  total 
contents  estimated  by  his  dilution  (200  cm.)  and  acidity 
method.  Twenty-five  cm.  of  the  undiluted  contents  are 
finely  divided  in  a  mortar,  neutralized  with  NaOH  solution, 
mixed  with  sand,  and  evaporated  on  a  water-bath.  The  oil 
is  extracted  with  ether,  the  ether  is  driven  off  by  evaporation, 
and  the  quantity  of  oil  is  weighed.  The  total  quantity  of  oil 
is  easily  calculated,  the  total  quantity  of  the  contents  being 
known.  Normally,  at  the  end  of  one  hour  about  four  gm. 
of  the  ten  gm.  of  oil  are  recovered. 

The  author  of  this  method  uses  it  also  as  a  secretion  test, 
and  saves  a  part  of  the  undiluted  contents  for  chemical 
analysis.  From  the  data  he  also  calculates  the  part  of  the 
removed  total  contents  which  consists  of  saliva  and  gastric 
secretions,  and  the  part  which  consists  of  the  administered 
test-meal.     Suppose,  for  example,  after  one  hour  four  gm.  of 


138  DISEASES  OF  THE   STOMACH. 

oil  are  recovered.  Four-tenths,  or  100  cm.,  of  the  test-meal, 
consequently,  were  left  in  the  stomach.  This  quantity,  sub- 
tracted from  the  total  quantity  of  contents,  gives  the  portion 
of  the  contents  which  consists  of  gastric  secretion  and  swal- 
lowed saliva. 

The  Water=test. — None  of  these  motor  tests  give  the  cause 
of  the  motor  insufficiency.  The  stagnation  or  retention  may 
be  due  either  to  obstruction  or  to  myasthenia.  The  stagna- 
tion of  myasthenia  is  a  stagnation  of  liquids.  In  obstruction 
(incomplete),  liquids  are  evacuated  much  more  readily  than 
semi -solid  food.  The  normal  stomach  evacuates  500  cm.  of 
water  (just  cold  enough  to  be  refreshing)  in  one  to  one  and 
one-half  hours.  If  the  tube  introduced  after  the  expiration  of 
one  and  one-half  hours  recovers  a  notable  quantity  of  water 
there  is  motor  insufficiency  which  is  in  all  probability  due  to 
myasthenia,  unless  obstruction  is  so  great  as  to  cause  almost 
complete  retention.  If  food  stagnates  or  is  retained,  and 
the  water  is  evacuated  within  the  normal  period,  the  trouble 
is  obstruction.  If  the  quantity  of  the  contents  after  a  test- 
meal  is  abnormally  large  and  the  specific  gravity  below  loio, 
and  if  the  water  is  evacuated  within  the  normal  period,  there 
is  excessive  secretion,  or  excessive  secretion  with  obstruction. 
The  water-test  is  useful  in  detecting  myasthenia  (first  and 
second  degrees  of  stagnation)  and  in  distinguishing  obstruc- 
tion from  myasthenia  during  their  stagnation  stages. 

Methods  of  Dehio  and  Rosenbach. — Some  information 
concerning  the  elasticity  of  the  stomach  may  be  obtained  by 
the  methods  of  Dehio  and  Rosenbach. 

The  method  of  Dehio  was  intended  for  the  purpose  of 
locating  the  lower  border  of  the  stomach;  but,  as  indicated 
by  Boas,  it  may  also  give  some  information  concerning  the 
distensibility  of  the  stomach.  Normally,  after  one  glass  of 
water  has  been  swallowed,  the  lower  border  of  the  dull  area 
(the  patient  standing)  is  about  1 1  cm.  below  the  tip  of  the 
ensiform  process.  Each  succeeding  glass  carries  the  limit 
of  the  dulness  about  two  cm.  lower,  until  after  the  fourth 
glass  the  lower  border  is  near  the  level  of  the  umbilicus.  If 
the  glasses  of  water  be  given  in  succession,  a  more  rapid  de- 
scent of  the  dull  area  than  normally  occurs  would  indicate 
that  the  stomach  wall  yields  too  readily  to  pressure. 

The  method  of  Rosenbach  is  based  on  the  same  principle 
as  the  method  of  Dehio,  but  the  change  in  the  upper  level 
of  the  water  is  determined  by  means  of  air  blown  through  the 
introduced  stomach-tube.     One  hundred  c.c.  of  water  are  in- 
troduced into  the  empty  stomach,  and  the  distance  of  the  level 


THE  FUNCTIONAL    SIGNS.  I  39 

of  the  fluid  from  the  incisor  teeth  is  determined  by  placing 
the  ear  over  the  stomach  while  air  is  slowly  blown  into  the 
stomach  through  the  tube  by  compressing  an  attached  bulb. 
The  cessation  of  the  bubbling  indicates  that  the  eye  of  the 
tube  (a  tube  with  one  opening  should  be  employed)  has 
emerged  from  the  water.  If  a  glass  of  water  be  introduced, 
the  change  in  the  level  of  the  fluid  is  again  determined. 
The  less  the  rise  in  the  level  of  the  fluid,  the  greater  is  the 
distensibility  of  the  stomach. 

Some  idea  of  the  tonicity  of  the  stomach  wall  may  be  ob- 
tained by  attaching  a  manometer  to  the  funnel  end  of  the 
tube  before  its  introduction  into  the  stomach  to  withdraw 
the  contents  after  a  test-meal.  The  greater  the  intragastric 
pressure,  the  more  strongly  is  the  stomach  contracted  on  its 
contents.  The  gastrograph  of  Einhorn  and  the  apparatus  of 
Hemmeter  are  of  little  clinical  interest,  although  a  practical 
method  of  accurately  displaying  the  peristalsis  of  the  stomach 
would  be  of  very  great  value.  One  of  the  best  practical  indi- 
cators of  the  tonicity  of  the  stomach  is  the  difference  in  the 
size  of  the  organ  when  it  is  moderately  full  and  when  it  is 
empty.  A  stomach  which  does  not  retract  when  it  is  empty 
has  lost  its  tone — its  elasticity.  The  stomach  retracts  about 
the  line  of  the  fixed  lesser  curvature.  Consequently,  the 
change  in  the  position  of  the  greater  curvature  displays  the 
change  in  the  size  of  the  organ  produced  by  its  retraction. 
Instrumental  methods  may  be  used  to  make  known  this  change 
of  position,  but  the  physical  signs  ordinarily  suffice  for  the 
purposes  of  practice. 

The  motor  signs  display  either  normal  muscular  activity  and 
work  or  reveal  some  pathological  variation  of  the  motor  func- 
tion. The  negative  diagnostic  value  of  the  normal  function 
should  not  be  forgotten.  When  the  functions  are  found  to  be 
right,  as  much  information  is  obtained  as  when  they  are  found 
to  be  wrong. 

The  pathological  variations  are  excessive  activity  and  insuf- 
ciency.  Excessive  activity  is  manifested  by  spasm — cardio- 
spasm, gastrospasm,  spasms  of  the  pylorus,  peristaltic  unrest. 
Insufficiency  is  due  either  to  a  diminution  of  muscular  power 
or  to  inability  to  overcome  some  mechanical  interference — 
gastroplegia,  myasthenia,  displacement,  inflammatory  or  can- 
cerous infiltration  of  the  muscular  coat,  pyloric  or  duodenal 
obstruction,  perigastric  adhesions,  deformity  of  the  stomach. 

In  regard  to  the  evacuation  of  the  stomach,  it  may  be  too 
rapid  or  too  slow.  Too  rapid  evacuation  occurs  in  pyloric 
incontinence,  which  may  be  a  dynamic  affection,  or  a  symptom 


I40  DISEASES  OF  THE  STOMACH. 

of  an   organic   disease,   particularly  cancer  (scirrhus),  which 
has  converted  the  pylorus  into  a  rigid,  open  canal. 

Delayed  evacuation  is  most  commonly  the  result  of  myas- 
thenia, the  forms  and  causes  of  which  are  discussed  in  the 
fourth  section  of  this  book.  The  other  causes  of  delayed  evac- 
uation, when  it  is  not  a  mere  temporary  condition  or  due 
to  excessive  secretion,  are  the  anatomical  diseases  already 
mentioned,  and  which  are  described  in  the  fifth  section  of 
this  volume.  It  is  important  to  remember  that  motor  insuf- 
ficiency may  be  absolute  and  relative,  temporary  and  per- 
sistent, dynamic  or  anatomical,  simple  or  complicated.  The 
motor  signs  are  all  symptoms — not  one  of  them  is  a  disease. 


3.  ABSORPTION. 

Little  is  known  concerning  the  physiology  and  pathology 
of  absorption  by  the  human  stomach.  It  is  uncertain  whether 
absorption,  which  occurs  to  a  very  small  extent,  is  a  physical 
process  of  diffusion  or  is  the  work  of  the  cells  which  cover  the 
mucous  membrane.  It  is  known  that  no  water  and  fat  are 
absorbed  by  the  human  stomach,  but  that  alcohol,  the  sugars, 
and  albumoses  are  absorbed  in  small  quantity.  In  the  ex- 
periments made  on  man  in  health  and  in  disease,  it  has  not 
been  possible  to  tell  how  much  the  results  obtained  have  been 
affected  by  gastric  secretion  and  evacuation. 

Jaworski  (1883)  determined  the  relative  absorbability  by 
the  human  stomach,  of  a  number  of  salts,  acid  carbonate  of 
magnesia  beine  the  most  absorbable.  These  results  mav  be 
thus  brieflv  presented:  H.,Mg  (CO.O2  >  HNaCOa  >  Na^SO,  > 
MgSO,  >  H.XaPO^  >  KCl  >  FeCU  >  NaCl.  These  results  may 
be  incorrect  for  those  salts  which,  like  NaCl,  exist  in  the 
gastric  juice. 

During  the  past  two  years  (method  and  results  described 
in  a  lecture  at  the  Polyclinic  in  October,  1886)  we  have  em- 
ployed the  following  test  of  absorption  :  The  yolks  of  four 
eggs  are  thoroughly  beaten  and  mixed  with  200  c.c.  of  dis- 
tilled water,  in  which  25  gm.  of  dextrose  (Merck)  has  been 
dissolved,  and  30  c.c.  of  whisky  are  added.  Two  hundred  c.c. 
of  the  mixture  are  given  on  an  empty  stomach,  the  balance 
being  utilized  for  the  estimation  of  the  percentages  of  fat  (ether 
extract)  and  dextrose  (ammonia  and  copper  solution).  After 
one  hour  the  contents  are  expressed  and  the  total  quantity  of 
contents  is  estimated  by  the  total  acidity  method  of  Mathieu. 


THE  FUNCTIONAL    SIGNS.  I4I 

The  percentages  of  fat  and  dextrose  in  the  contents  are  esti- 
mated and  a  qualitative  test  (liquor  potassa  and  iodin  solu- 
tion) is  made  for  alcohol.  From  these  data  it  can  be  readily 
determined  how  much  fat  has  been  evacuated  and  conse- 
quently the  proportion  of  the  contents,  how  much  of  the 
contents  consists  of  secretion,  how  the  relative  percentages 
(not  affected  by  evacuation  nor  by  dilution)  of  fat  and  dex- 
trose have  been  altered,  and  consequently  how  much  of  the 
dextrose  has  been  absorbed. 

The  old  method  of  Penzoldt  and  Faber  is  of  no  clinical 
value.  Three  grains  of  pure  iodid  of  potassium  are  admin- 
istered in  a  capsule  while  the  stomach  is  empty,  and  the 
moment  of  the  appearance  of  iodin  in  the  saliva  is  detected 
by  using  starch  paper  and  fuming  nitric  acid.  Normally,  the 
reaction  in  the  saliva  is  positive  in  fifteen  minutes.  In  some 
diseases  its  appearance  may  be  delayed  ;  but  these  diseases 
(cancer,  retention)  are  precisely  the  ones  in  which  motor 
insufficiency  occurs  and  free  HCl  is  often  absent.  Little  is 
known  about  the  many  circumstances  which  delay  the 
absorption  of  the  iodid,  and  the  test  has  proved  almost 
worthless  at  the  bedside. 


4.  DIGESTIVE  WORK. 

The  chemical  transformation  of  the  food,  which  is  pro- 
duced in  the  stomach  by  the  saliva  and  by  the  gastric  juices, 
represents  the  digestive  work  done  in  this  organ.  The 
digestive  work  which  is  performed  in  the  stomach  after  a 
test-meal  is  displayed  by  the  digestive  products  and  by  the 
portion  of  the  meal  that  remains  undigested.  The  diges- 
tive work  is  expended  on  the  carbohydrates  and  on  the 
proteids. 

The  carbohydrates  are  not  digested  by  the  gastric  juice, 
but  the  transformation  by  the  saliva  is  modified  by  the  dis- 
eases of  the  stomach.  The  inspection  of  the  expressed  con- 
tents may  show  that  the  starch  remains  for  the  greater  part 
unchanged,  or  has  been  normally  digested,  or  has  been 
rapidly  and  completely  dissolved.  The  normal  contents  are 
a  finely  divided  or  nearly  homogeneous  mixture.  If  the 
starch  digestion  is  arrested  too  early  by  excessive  gastric 
secretion,  the  bread,  or  bread  and  potato,  are  only  partly  dis- 
solved;  Lugol's  solution  gives  a  blue  or  brownish  coloration. 
If  starch  digestion  is  very  active  (subacidity),  the  solution 
and  transformation  is  more  complete  ;  Lugol's  solution  gives 


142  DISEASES  OF  THE  STOMACH. 

a  reddish  or  no  coloration,  and  Fehling's  solution  is  posi- 
tive. The  accumulation  of  the  products  of  starch  digestion 
increases  the  specific  gravity  of  the  filtrate  of  the  contents 
obtained  after  the  test-meals,  unless  secretion  is  excessive. 
Normally,  the  specific  gravity  of  the  filtrate  after  the  test- 
breakfast  is  loio  to  1015;  after  See's  meal,  1015  ;  after 
Riegel's  dinner,  1015  to  1020.  If  a  large  quantity  of  starch 
products  is  present,  either  the  evacuation  of  the  stomach  is  too 
slow  or  absorption  is  diminished,  or  both  conditions  are  pres- 
ent. Digestive  products  do  not  accumulate  in  the  normal 
stomach. 

The  digestion  of  the  proteids  is  revealed  by  inspection  and 
by  chemical  tests,  and  is  displayed  best  by  the  Riegel  or  See 
meals.  The  proteids  may  be  rapidly  digested  as  in  active  or 
excessive  secretion  ;  or  they  may  remain  undissolved  and 
untransformed  in  anacidity.  The  methods  of  distinguishing 
syntonin,  albumoses,  and  peptones  is  described  elsewhere, 
but  the  biuret  test  gives  a  rough  idea  of  the  activity  of 
peptonization.  The  products  of  proteid  digestion  accumu- 
late in  the  stomach  only  when  there  is  motor  insufificiency. 

The  digestive  work  done  by  the  stomach  in  the  various 
diseases  is  described  in  the  fourth  and  fifth  sections.  By 
mere  inspection  of  the  physical  properties  of  the  contents, 
information  concerning  the  functional  power  of  the  stomach 
may  be  obtained,  which  is  very  valuable  both  in  diagnosis  and 
in  the  dietetic  treatment. 


CHAPTER   IV. 

THE  BACTERIOLOGICAL  SIGNS. 

It  is  a  remarkable  clinical  fact  that  the  micro-organisms 
of  the  stomach  are  quite  constant,  and  are  characteristic  of 
the  qualities  of  the  contents  and  of  the  motor  function  of  the 
stomach  in  which  they  grow.  As  a  rule,  germs  do  not  thrive 
in  an  acid  medium  so  well  as  in  an  alkaline  or  a  nearly  neu- 
tral culture.  Consequently,  a  large  number  die  rapidly  or 
degenerate,  or  form  the  more  resisting  spores  when  they 
remain  in  the  acid  stomach.  The  germicidal  power  of  the 
gastric  juice  is  important,  but  it  is  incomplete,  both  in  health 
and,  to  a  greater  degree,  in  disease.     The  germs  swallowed 


THE   BACTERIOLOGICAL   SIGNS.  1 43 

during  the  period  of  functional  rest  and  during  the  period 
when  no  hydrochloric  acid  is  free  in  the  stomach,  may  escape 
uninjured  into  the  intestines  and  find  there  a  persistent  and 
favorable  soil.  Their  passage  through  the  stomach  may  be 
too  rapid  to  allow  time  for  their  destruction.  The  healthy 
stomach  may  fail  to  protect  the  organism  against  invasion 
even  by  the  pathogenic  germs.  The  diseased  stomach  may 
become  a  breeding  receptacle,  particularly  for  the  saprophytic 
germs.  The  hydrochloric  acid  influences  only  the  quality 
of  the  germ  growth  which  occurs  in  the  d4seases  of  the 
stomach  accompanied  by  motor  insufficiency. 

But  apart  from  the  acid  reaction,  the  composition  of  the 
diet  exercises  a  great  influence  on  the  development  of  the 
lower  forms  of  life.  Each  germ  has  its  own  peculiar  habitat, 
its  favorite  culture  soil,  and  dies  when  it  can  not  adapt  itself 
to  the  sudden  changes  which  occur  in  the  contents  of  the 
stomach.  On  the  other  hand,  their  increase  is  rapid  in  a 
favorable  soil. 

But  of  more  influence  than  either  the  acidity  and  the  com- 
position of  the  contents  of  the  stomach  are  the  intermittence 
of  the  food  supply  and  the  complete  emptiness  of  the  resting 
organ,  which,  when  normal,  evacuates  the  germs  along  with 
the  chyme  into  the  duodenum.  Thus  the  normal  stomach  is 
intermittently  empty  and  clean  and  without  a  culture  soil. 
Consequently,  in  the  normal  organ  germs  do  not  have  time, 
during  the  short  digestive  period,  to  manifest  their  very  active 
powers  of  growth  and  proliferation.  The  churning  move- 
ments of  the  stomach  also  help. to  keep  its  contents  sweet. 
Constant  motion  is  very  destructive  to  some  forms  of  germ 
life. 

Naturally,  the  flora  of  the  stomach  is  dependent  upon  the 
number  of  germs  which  obtain  entrance  there.  The  supply 
of  these  is  abundant, — from  food  and  drink,  from  the  mouth, 
the  nose,  and  the  throat,  and  probably  from  the  intestines. 
The  opportunities  afforded  by  pathological  conditions  are 
readily  used. 

The  prevailing  classification  of  bacteria  is  based  on  their 
form — cocci,  bacilli,  spirilli.  Besides  these,  we  have  other 
germs — the  molds  and  the  yeasts.  The  particular  kind  of 
germ  found,  with  but  few  exceptions,  is  of  little  diagnostic 
value.  It  is  probable  that  a  more  complete  study  and  a 
more  exact  control  of  the  conditions  would  extend  this  short 
limit. 

The  quantity  of  germs  found  denotes  more  favorable  con- 
ditions of  growth.     This   may  be  referred   to   the   quality  of 


144  DISEASES  OF  THE  STOMACH. 

the  soil,  but  the  richness  and  the  active  growth  of  the  flora  is, 
also,  directly  and  closely  dependent  on  the  delay  or  the  failure 
of  the  stomach  to  empty  itself. 

The  germs  of  the  stomach  under  consideration  are  not 
pathogenic,  but  live  on  and  in  dead  matter.  Consequently, 
their  existence  is  made  manifest  by  changes  in  the  contents 
on  which  they  live.  The  acids,  the  gases,  and  the  toxins  of 
fermentation  and  putrefaction  are  thus  developed. 

The  bacteriological  signs  consist  of  the  kind  and  the  num- 
ber of  the  micro-organisms,  and  of  the  products  which  they 
form  by  fermentation  and  putrefaction.  The  products  which 
are  of  practical  importance  are  the  organic  acids,  the  gases, 
and  the  toxins. 


Fig.  lo.— Sarcinae  veniriculi  from  stomach-contents,  X  530;  stained  with  methylene  blue 
(authors'  specimen). 

I.  The  Kind  of  Germ. — The  many  kinds  of  germs  found  in 
the  healthy  stomach  and  in  the  pathological  stomach  have 
not.  been  isolated  and  studied;  but  it  will  not  be  denied  by 
those  who  frequently  make  a  microscopical  examination  of 
the  stomach-contents  that  the  individual  forms  are  very 
numerous.  Only  sarcina.  }'east,  and  the  bacillus  geniculatus 
have  a  definite  pathological  meaning.  And  tl'.is  is  true  of 
these  three  only  when  they  are  persistently  present  in  large 
quantities  and  in  active  growth. 

Many  forms  of  sarcinae  exist  in  the  air,  and  they  may  find 
their  way  into  the  stomach,  and,  under  fa\orable  conditions, 
may  there  proliferate.  Oppler,  who  has  best  studied  these 
cocci  in  the  stomach-contents,  succeeded  in  isolating  five 
varieties,  presenting  distinct  color  and  culture  peculiarities. 
The  cultures  possess  only  a  scientific  interest ;  practically,  we 


THE    BACTERIOLOGICAL    SIGNS. 


145 


are  concerned  only  with  their  persistent  presence  in  large 
quantities  in  the  contents  of  the  stomach. 

These  cocci  are  about  2.5  //  in  diameter  and  appear  in 
small  cubical  groups  of  eight,  the  packages  or  bales  being 
marked  by  lines  running  at  right  angles.  Larger  packets 
may  be  formed.  They  may  be  found  very  loosely  united  or 
separated,  and  are  small  when  undergoing  degeneration. 

Sarcinee  in  large  quantities  are  only  found  in  benign  forms  of 
gastric  stagnation  or  retention  with  free  HCl.  They  can  not 
live  in  the  lactic  acid  contents  of  carcinoma.  In  small  num- 
ber they  may  be  found  in  cancer,  during  the  free  HCl  stage, 
in  gastritis,  in  ulcer,  in  gastroptosis,  and  in  the  dynamic 
affections.  Their  presence  in  these  diseases  is  inconstant  and 
rare.     Their  persistent  growth  in  large  numbers  is  character- 


Fig.  II. — Yeast  from  stomach-contents;  X  530  (authors'  specimen). 


istic  of  retention   due  to   myasthenia   and   to   non-malignant 
obstruction. 

Yeast,  which  grows  by  budding  and  occurs  in  single  cells, 
or  in  strings  of  cells,  clear  and  bright,  and  staining  yellow 
with  iodin,  is  often  found  in  the  stomach-contents;  but  it 
only  grows  and  flourishes  there  when  there  are  motor  insuffi- 
ciency and  a  suitable  soil.  The  acidity  of  the  contents  of  the 
stomach  has  little  influence  on  the  growth  of  the  yeast.  It 
matters  little  whether  the  reaction  is  alkaline,  neutral,  or 
strongly  acid.  Even  excessive  hydrochloric  acidity  does  not 
arrest  its  growth,  nor  does  carcinoma  prevent  its  development. 
Whenever  there  is  motor  insufficiency  yeast  may  be  found, 
but  it  is  not  very  vigorous  except  in  gastric  retention,  when  the 
yeast  accumulates  in  large  quantity,  and  the  microscope  shows 
that  the  plants  are  growing  rapidly.     The  proliferation  of  the 


146 


DISEASES  OF  THE  STOMACH. 


yeast  is  proportionate  to  the  motor  insufficiency  and  to  the 
richness  of  the  diet  in  fermentable  matter.  Yeast  is  often 
present  in  small  quantity  in  all  the  diseases  of  the  stomach, 
except  simple  ulcer. 

The  bacillus  g:eniculatus  (Fig.  12)  is  present  in  very  large 
numbers  in  carcinoma  (Boas),  and  is  sufficient  to  render  a  case 
suspicious.  This  bacillus  consists  of  cells  a  little  smaller  than 
the  bacillus  subtilis,  arranged  often  in  a  zigzag  line,  or  in  pairs, 
joined  end  to  end  so  as  to  form  an  angle.  It  does  not  color 
with  iodin,  but  colors  homogeneously  with  fuchsin.  It  is 
large,  devoid  of  motion,  may  be  easily  seen  without  staining, 
and  is  always  present  in  carcinoma  when  the  contents  contain  a 
notable  quantity  of  lactic  acid.  It  develops  in  acid-sweetened 
bouillon  and  produces  lactic  acid  (Kaufmann). 


Fig.  12. — Bacillus  geiiiculatus  from  stomach-contents  ;  X  730:  a,  spore-formation  ;  oval 
spores  in  center,  ends  pale  and  indistinct:  ^,  niultiplication  by  cell-division  ;  c,  normal 
cell  arranged  in  a  zigzag  line  ;  length,  4  to  8  /x  ;  width,  about  0.7  fi  (authors'  specimen). 


These  are  the  only  varieties — viz.:  sarcina  ventriculi,  yeast, 
and  the  bacillus  geniculatus,  whose  simple  growth  in  the 
stomach  signifies  that  the  organ  is  diseased.  The  sarcinae,  in 
large  quantities,  are  almost  exclusively  found  in  benign  reten- 
tion with  free  HCl.  Yeast  finds  a  most  favorable  soil  in 
stagnation  or  retention,  regardless  of  the  kind  or  the  degree 
of  acidity.  The  bacillus  geniculatus  is  constantly  present  in 
cancerous  obstruction  of  the  pylorus  which  produces  reten- 
tion. It  is  sometimes  absent  in  other  forms  of  carcinoma, 
but  its  persistent  presence  in  large  numbers  is  almost  charac- 
teristic of  malignant  disease  of  the  stomach. 

2.  The  Number  of  Germs. — The  quantity  and  the  general 
character  of  the  micro-organisms  present  are  of  diagnostic 
value.     The   normal  stomach  is  a  bad  medium  for  bacterial 


THE  BACTERIOLOGICAL    SIGNS.  1 4/ 

growth,  and  the  presence  of  germs  here  is  seemingly  tolerated 
only  under  the  condition  of  quiescence;  some  forms  are 
equal  to  this  struggle  for  life,  but  are  incapable  of  thriving. 
In  motor  insufficiency  the  conditions  are  more  favorable,  and 
the  rapidity  of  development  and  the  many  varieties  of  germs 
are  often  remarkable;  but  possibly  the  many  kinds  may  be 
only  stages  in  the  development  of  a  few  germs,  and  may 
be  a  sign  of  the  rapid  proliferation  of  a  smaller  number  of 
distinct  kinds  than  at  first  sight  would  appear  to  be  the  case. 
This  lively  pathological  proliferation  may  be  evident  at  a 
glance  through  the  microscope  and  is  a  sign  of  gastric  reten- 
tion. Whenever  the  stomach  completely  evacuates*  its  con- 
tents within  the  normal  period,  the  number  of  germs  found 
in  it  is  never  large. 

3.  Qerm=Products. — The  zymogenic  and  putrefactive  bac- 
teria are  the  most  important  in  the  pathology  of  the  stomach. 
These,  by  their  existence  or  growth,  cause  and  perpetuate 
such  changes  in  the  chemical  composition  or  constitution 
of  the  complex  matter  that  the  resulting  substances  become 
simpler  and  have  a  less  force  value. 

This  fermentative  and  putrefactive  power  is  not  without 
limitations,  and  the  soil  becomes  exhausted  and  the  process 
ceases.  It  is  probable  that  all  bacteria  in  the  proper  medium 
are  zymogenic,  and  some  are  capable  of  producing  both  fer- 
mentation and  putrefaction;  but  comparatively  few  possess 
these  powers  to  such  a  degree  as  to  form  notable  quantities 
of  germ  products  in  the  stomach.  Fermentation  is  much 
more  common  in  the  stomach  than  is  putrefaction.  The 
forms  of  fermentation  of  practical  importance  are  lactic,  bu- 
tyric, acetic,  and  alcoholic  fermentation. 

[a)  Lactic  Acid  Fermentation. — This  form  of  fermentation  is 
produced  by  a  variety  of  germs,  and  is  often  followed  by 
butyric  acid  fermentation,  CeHi^Og  (glucose)  =  2(C3Ho03)  (lac- 
tic acid)  =  C4HSO2 (butyric  acid)  -\-  2CO2  +  H4.  The  process 
is  not  so  simple  as  represented  by  the  equations,  for  other  in- 
termediate acids  and  gases  are  formed.  Lactic  acid  may  be 
destroyed  by  oxidizing  germs. 

The  bacillus  acidi  lactici  (Hueppe)  is  short, — about  four 
times  longer  than  it  is  thick, — motionless,  builds  spores,  and  is 
aerobic.  It  is  very  active  at  the  temperature  of  the  stomach, 
and  converts  glucose  and  lactose  into  lactic  acid  with  the 
evolution  of  CO2.  It  does  not  liquefy  gelatin,  and  it  forms 
colonies.  Many  other  bacteria  produce  the  same  result. 
Among  these  are  the  bacillus  geniculatus  and  two  cocci 
found   in   the   saliva.     The  bacterium  coli   commune,  some- 


148  DISEASES  OF  THE  STOMACH. 

times  fouiul  in  the  stomach,  is  capable  of  producing  lactic 
acid.  Lactic  acid  may  also  be  introduced  into  the  stomach 
with  the  food  and  be  separated  from  the  lactates  by  the 
stronger  HCl  of  secretion.  The  introduced  and  the  liberated 
acid  have  no  pathological  significance. 

Lactic  acid  possesses  a  definite  diagnostic  value.  In  many 
diseases  of  the  stomach  lactic  acid  may  be  formed  in  small 
quantities;  but  in  few  diseases  is  it  produced  in  notable  quan- 
tity, after  the  stomach  has  been  thoroughly  washed  out  in  the 
evening  and  a  lactic-acid-free  test-meal  has  been  given  on  the 
following  morning.  The  formation  of  lactic  acid  takes  place 
in  the  human  stomach  only  in  very  special  conditions,  and 
these  conditions  are  rarely  fulfilled,  except  in  carcinoma.  In 
the  first  place,  secretion  must  be  dimini.shed,  and,  indeed,  to 
such  an  extent  that  no  free  HCl  exists  in  the  contents  obtained 
at  the  usual  time  after  a  test-meal.  The  lactic  acid  bacilli  are 
quickly  rendered  inactive  by  free  hydrochloric  acid,  and  even 
hydrochloric  acid  in  organic  combination  suffices,  when  in 
notable  quantity  (o.  1 2  per  cent,  or  35),  to  arrest  lactic  acid  for- 
mation. Whenever  lactic  acid  coexists  with  free  hydrochloric 
acid,  it  has  either  been  introduced  into  the  stomach  or  formed 
in  the  stomach  by  the  decomposition  of  lactates.  In  the  second 
place,  retention  or  malignant  stagnation  must  exist.  Even  in 
achylia,  lactic  acid  is  not  formed  by  germs  in  the  stomach 
whenever  the  stomach  completely  evacuates  its  contents  within 
the  normal  period.  This  rule  is  without  exception,  if  the 
stomach  be  thoroughly  washed  out  and  a  test-meal,  like  the 
oatmeal  test  of  Boas,  be  given.  The  time  such  a  meal  re- 
mains in  a  stomach  whose  motor  function  is  sufficient  is  too 
short  for  lactic  acid  to  be  formed  by  bacilli ;  but  the  motor 
insufficiency  need  only  be  slight,  if  it  be  associated  with 
arrested  peristalsis  of  a  portion  of  the  wall  of  the  stomach. 
This  localized  arrested  peristalsis  may  be  due  to  adhesions  or 
to  a  localized  perigastritis,  or  to  a  new  growth.  Practically, 
however,  the  uncontrollable  formation  of  a  notable  quantity 
of  lactic  acid  in  slight  motor  insufficiency  occurs  only  in 
cancer,  which  pernn'ts  the  accumulation  of  germs  and  the  re- 
tention of  food  upon  its  surface.  Lactic  acid  fermentation  may 
occur  in  cither  benign  or  malignant  retention,  accompanied  by 
achylia.  But  the  association  of  benign  retention  with  achylia 
is  very  rare.  Finally,  the  formation  of  lactic  acid  is  depend- 
ent on  the  presence  of  lactic-acid-forming  germs  in  a  suitable 
culture  soil.  Any  of  the  test-meals  form  a  suitable  soil,  and 
the  saliva  may  furnish  the  proper  germs,  which  grow  and 
accumulate  in  the  stomach  under  special  circumstances.    The 


THE   BACTEKIOLOGICAL    SIGNS.  149 

activity  of  lactic  acid  formation  is  partly  dependent  on  the 
richness  of  the  contents  in  ptyalin  digestive  products. 

The  essential  conditions  of  lactic  acid  formation  make  clear 
the  diagnostic  value  of  this  bacteriological  sign.  Boas  con- 
tends that  the  persistent  uncontrollable  formation  of  lactic 
acid  in  noteworthy  quantity  during  the  digestion  of  a  saucer 
of  lactic-acid-free  oatmeal  is  a  specific  sign  of  cancer.  This 
contention  is  almost  universally  true,  the  exceedingly  rare 
exceptions  occurring  in  diseases  which  usually  possess  other 
characteristic  symptoms  and  signs,  and  which  do  not  show 
the  essential  clinical  characters  of  carcinoma. 

Persistent,  uncontrollable,  and  noteworthy  formation  of 
lactic  acid  may  be  an  early  sign  of  carcinoma.  It  is  not  a 
pathognomonic  sign,  but  it  is  one  of  value,  which  should 
be  confirmed  by  the  presence  of  other  symptoms  of  the  same 
disease.  It  may  not  appear  until  late  in  the  development  of 
cancer.  A  malignant  disease  of  the  stomach  may  run  its 
entire  course  without  lactic  acid  formation.  We  have  seen 
almost  the  entire  gastric  wall  and  the  pylorus  infiltrated, 
without  the  appearance  of  lactic  acid  in  the  repeatedly 
examined  contents  up  to  within  a  few  days  of  death.  The 
stomach,  however,  in  this  case  was  very  small,  and  evacuated 
the  test-breakfast  completely  in  less  than  one  hour.  The 
absence  of  lactic  acid  formation  does  not  exclude  cancer.  Its 
presence  means  that  the  conditions  of  its  formation  are  real- 
ized. Its  persistent  formation  in  noteworthy  quantity  (0.05  to 
0.2  per  cent.)  after  thorough  lavage,  during  the  digestion  of 
Boas'  oatmeal  test  or  of  the  Ewald-Boas  test-breakfast,  is 
an  almost  certain  sign  of  carcinoma,  for  in  achylia  accom- 
panied by  benign  retention  the  stomach  can  and  would  be 
cleansed.  The  grave  suspicion  should  be  confirmed  by  other 
evidences  of  cancer,  and  by  the  absence  of  the  signs  of  a 
disease  which  might  be  accompanied  by  the  conditions  essen- 
tial to  lactic  acid  formation. 

Lactic  acid  formed  by  bacilli  in  the  stomach  is  always 'a 
pathological  product,  and  its  detection  is  consequently  very 
important  in  diagnosis.  Two  tests  are  commonly  used — viz., 
the  iron  test  of  Uffelmann  and  the  oxidation  aldehyd  test 
of  Boas.  The  reaction  of  Uffelmann,  which  is  qualitative, 
usually  suffices.  When  this  reaction  has  been  repeatedly 
positive  it  may  be  confirmed  by  the  test  of  Boas,  which  is 
qualitative  and  quantitative.  A  quantity  of  lactic  acid  which 
does  not  give  the  Uffelmann  reaction  has  very  little  diagnostic 
significance.  It  is  a  waste  of  time  to  make  either  test  when 
free  hydrochloric  acid  is  present. 


150  DISEASES  OF  THE  STOMACH. 

Uffelniainis  Method. — UfTelmann  recommended  a  clear, 
amethyst-blue  solution  containing  carbolic  acid  and  chlorid 
of  iron.  The  reagent  may  be  prepared  by  adding  ten  c.c.  of 
a  four  per  cent,  aqueous  solution  of  carbolic  acid  to  20  c.c. 
of  distilled  water  containing  one  drop  of  the  official  solution 
of  the  chlorid  of  iron  ;  or  it  may  be  prepared  by  dissolving 
four  drops  of  pure  liquefied  carbolic  acid  in  20  c.c  of  dis- 
tilled water  and  adding  one  drop  of  the  solution  of  the  per- 
chlorid  of  iron.  The  reagent  must  always  be  prepared  at 
the  moment  when  the  test  is  made.  The  blue  only  serves  as 
a  contrast  color,  and  the  reagent  may  be  prepared  by  omitting 
the  carbolic  acid,  the  characteristic  reaction  being  the 
yellowish-green  color  produced  by  the  formation  of  the 
lactate  of  iron.  It  is  recommended  that  the  reagent  be  pre- 
pared by  adding  five  drops  of  a  ten  per  cent,  dilution  of 
liquor  ferri  chloridi  (chemical  reagent)  to  50  c.c.  of  distilled 
water.     This  solution  is  clear  and  its  color  is  imperceptible. 

The  test  is  made  by  using  either  the  filtered  contents  or 
an  ether  extract  of  the  same.  When  the  filtrate  is  employed, 
the  method  of  Kelling  is  to  be  preferred.  Five  c.c.  of  the 
filtrate  are  diluted  to  50  c.c.  by  means  of  distilled  water,  and 
one  or  two  drops  of  a  five  per  cent,  solution  of  sesquichlorid 
of  iron  (better,  two  drops  of  the  ten  per  cent,  dilution)  are 
added.  The  yellowish-green  tinge  indicates  the  presence  of 
lactic  acid ;  or  the  reaction  may  be  made  by  employing  the 
solution  containing  two  drops  of  the  ten  per  cent,  dilution  of 
the  official  liquor  ferri  chloridi  in  20  c.c.  of  distilled  water. 
Five  c.c.  of  the  filtrate  are  added  to  20  c.c.  of  the  reagent, 
and  the  coloration  is  noted. 

The  liability  to  error  is  diminished  by  first  extracting  the 
lactic  acid  from  the  filtered  contents  with  ether,  and  by 
testing  the  ether  extract.  Two  methods  may  be  employed. 
Five  c.c.  of  the  contents  are  shaken  with  five  times  their 
quantity  of  ether.  After  separation,  the  clear  ether  is 
decanted.  Five  c.c.  of  the  ether  extract  are  shaken  with  20 
c.c.  of  the  iron  reagent  (containing  two  drops  of  the  ten  per 
cent,  dilution).  If  lactic  acid  is  present  in  the  ether  extract, 
the  lactate  of  iron  formed  colors  the  water  the  characteris- 
tic straw-green.  Or  the  method  of  Strauss  may  be  used  : 
A  glass  cylinder,  graduated  at  5  and  25  c.c.  and  fitted  with 
a  stop-cock,  is  used.  Five  c.c.  of  the  filtered  contents  are 
first  added,  and  thoroughly  shaken  with  ether  which  has 
been  added  until  the  level  of  the  fluid  has  been  brought  to 
the  25  c.c.  mark.  After  standing  until  separation  takes 
place,  the  stop-cock  is  opened,  and  the  filtered  contents  and 


THE   BACTERIOLOGICAL    SIGNS.  I5I 

the  ether  are  let  run  out  until  the  ether  is  lowered  to 
the  5  c.c.  mark.  The  cylinder  is  next  filled  with  distilled 
water  to  the  25  c.c.  mark.  Two  drops  of  a  ten  per  cent, 
dilution  of  liquor  ferri  chloridi  are  added,  and  the  coloration 
is  noted. 

The  method  of  de  Yong  is  simple  and  excellent.  One  or 
two  drops  of  HCl  are  added  to  five  c.c.  of  the  filtered  gastric 
contents,  which  is  slowly  evaporated  to  a  syrupy  consistency, 
permitted  to  cool,  and  extracted  with  ether.  Five  c.c.  of  dis- 
tilled water  are  heated  to  the  boiling-point,  and  the  ether 
extract  is  slowly  added.  The  ether  is  driven  off  by  the  heat 
of  the  water,  and  the  extracted  lactic  acid  is  left  in  solution 
in  the  same  quantity  of  distilled  water  as  the  quantity  of 
gastric  contents  originally  employed.  One  drop  of  a  five  per 
cent,  solution  of  chlorid  of  iron  is  added  after  the  solution  has 
become  cold,  and  the  intensity  of  the  greenish-yellow  color- 
ation is  compared  with  that  produced  by  adding  one  drop  of 
the  iron  solution  to  five  c.c.  of  solutions  of  lactic  acid  varying 
in  strength  from  0.5  to  4.0  :  looo. 

All  these  methods,  when  properly  followed,  give  trust- 
worthy results.  The  yellowish-green  coloration  is  slight  when 
lactic  acid  is  present  in  i  :  3000;  but  it  is  very  clear  when 
I  :  1000  lactic  acid  is  present.  The  reaction  is,  conse- 
quently, sufficiently  sensitive  for  practical  purposes,  for  a 
smaller  quantity  of  lactic  acid  than  is  revealed  by  the  test 
possesses  very  little  diagnostic  significance.  It  is  strongly 
recommended,  for  the  purpose  of  a  comparison,  that  the  same 
relative  quantity  of  contents  (five  c.c.)  be  always  employed, 
and  that  the  reagent  contain  the  same  quantity  of  the  iron 
chlorid  (two  drops  of  a  ten  per  cent,  dilution  of  the  liquor 
ferri  chloridi  to  20  c.c.  of  distilled  water).  The  peculiar 
yellowish-green  coloration  only  is  characteristic  of  lactic 
acid.  It  is  advisable  to  make  a  control  test  with  five  c.c.  of  a 
solution  of  lactic  acid  (i  :  lOOo),  using  the  same  reagent  in 
both  tests. 

A  number  of  substances  give  a  similar  coloration  to  that  of 
lactic  acid — cyanid  of  potash  in  the  saliva  (color  remains  after 
the  addition  of  HCl  but  is  discharged  by  corrosive  sublimate), 
alcohol,  sugar,  phosphates,  carbonates,  oxalic  acid,  tartaric 
acid,  butyric  acid,  etc.  The  coloration,  when  these  sub- 
stances are  present  in  sufficient  quantity,  resembles,  but  is 
not  the  same  as,  that  of  lactic  acid.  It  is  always  best  to  use 
the  ether  extract,  and  to  make  a  control  test.  Under  the 
proper  precautions,  the  Uffelmann  reaction  is  thoroughly  trust- 
worthy, and  suffices,  ordinarily,  for  all  practical  purposes. 


152  J)/S/iASl<S  OF  THE  STOMACH. 

The  Method  of  Boas. — The  principle  of  Boas'  method,  which 
is  both  qualitative  and  quantitative,  is  very  simple.  The 
lactic  acid  is  converted  by  oxidation,  under  the  necessary  pre- 
cautions, into  acetaldehyd  and  formic  acid.  The  acetaldehyd 
is  tested  for  and  estimated  by  using  Lieben's  reagent.  The 
process  is  very  long  and  tedious,  and  had  better  be  submitted 
for  its  performance  to  an  expert  chemist.  The  qualitative 
analysis  requires  about  two  hours,  and  the  quantitative  about 
three  hours,  for  its  completion.  It  is  an  e.xcellent  method  of 
research,  which  we  find  it  rarely  necessary  to  employ  in 
practice. 

{b)  Butyric  Acid  Fermentation. — There  are  several  bacteria 
which  produce  butyric  acid  out  of  carbohydrates :  The 
bacillus  butyricus  (Prazmowski)  is  a  very  common  form,  and 
is  very  active  in  its  movements,  anaerobic,  and  builds  central 
spores,  around  which  the  cell  swells  and  lets  the  spore  escape 
at  the  end,  after  enveloping  it  like  a  capsule.  In  starch  and 
sugar  solutions,  and  out  of  lactates  or  lactic  acid,  it  forms 
butyric  acid,  hydrogen,  and  carbonic  acid.  With  iodin,  like 
starch  ("  amylobacter"),  it  stains — except  in  sugar  solutions — 
deep  blue.  It  does  not  liquefy  gelatin.  The  bacillus  butyricus 
(Hueppe)  also  builds  central  spores,  but  is  aerobic,  and  lique- 
fies gelatin  and  coagulates  milk  without  changing  its  reac- 
tion.    Out  of  lactates  and  lactic  acid  it  builds  butyric  acid. 

2(C3lIe03)  ==   C.HgO.,    +  2(C0,)   +  4(H). 
(Lactic  Acid)    (Butyric  Acid) 

The  o'idium  lactici  is  abundantly  present  in  some  cases  of 
retention  with  no  free  HCl.  It  forms  butyric  acid  and 
hydrogen.  The  formation  of  hydrogen  in  the  stomach  dis- 
appears with  the  germ,  and  it  also  forms  hydrogen  in  the 
fermentation  tubes.  Butyric  acid  may  be  split  from  fat  by 
the  secretion  of  the  stomach  (probably  a  ferment),  or  may  be 
introduced  into  the  stomach  from  without.  The  accumulation 
of  the  acid  in  the  stomach  is  due  to  stagnation  or  to  retention. 
The  formation  in  the  stomach  is  conditioned  by  stagnation 
and  by  a  diet  which  furnishes  the  germs  with  a  proper  soil. 
It  occurs  often  in  association  with  lactic  acid  fermentation, 
the  butyric  acid  being  formed  out  of  the  lactic  acid.  Butyric 
acid  is  also  formed  in  stagnation  accompanied  by  normal  or 
excessive  HCl  secretion.  The  butyric  fermentation  is  not 
determined  by  the  disease,  but  by  the  stagnation,  by  the 
supply  of  germs,  and  by  a  proper  soil.  It  occurs  in  the  mild 
form  of  stagnation  and  in  retention,  and  regardless  of  the 
degree   and    the    form  of   acidity.     It    is    most    common    in 


THE   BACTERIOLOGICAL    SIGNS.  1 53 

chronic  gastritis,  cancer,  myasthenia,  and  pyloric  obstruction. 
Butyric  acid  is  a  very  strong  irritant  to  the  stomach,  and  is 
also  toxic.  Butyric  is  the  most  frequent  form  of  acute  gastric 
fermentation,  but  the  formation  of  butyric  acid  is  dependent 
upon  the  diet  and  upon  little  extraneous  accidents  rather  than 
upon  any  particular  disease  of  the  stomach. 

Butyric  acid  may  be  detected  by  its  characteristic  odor, 
which  presents  the  most  delicate  test  for  it.  Like  the  other 
volatile  acids  of  the  contents,  it  reddens  a  moistened  blue 
litmus  paper  held  in  the  end  of  a  tube  in  which  some  of  the 
contents  are  being  boiled.  It  may  be  detected  by  distilla- 
tion or  by  extraction  with  large  quantities  of  ether,  and  by 
adding  to  the  distillate  or  residue  a  large  quantity  of  chlorid 
of  calcium  powder.  Oil-drops  are  thus  formed  having  the 
peculiar  rancid  odor. 

{c)  Acetic  Fermentation. — Acetic  fermentation  is  commonly 
due  to  the  mycoderm  aceti,  which  forms  only  surface  colo- 
nies, and  below  a  temperature  of  35°  C,  and,  consequently, 
can  not  take  place  in  the  stomach.  But  this  form  of  fermen- 
tation does  occur  in  the  stomach,  and  is  produced  by  other 
germs. 

Acetic  fermentation  is  quite  frequent  in  alcoholism,  espe- 
cially when  new,  incompletely  fermented  drinks  have  been 
taken.  The  conversion  of  ethyl  alcohol  into  acetic  acid  is  an 
oxidation  process,  aldehyd  being  a  middle  product. 

C2H5OH  +  0  =  CH3C0H  -f-  HjO. 
CH3COH  -f  O  =  CHjCOOH. 

This  form  of  fermentation  may  occur  whenever  there  is 
stagnation  or  retention  or  when  the  stomach  is  kept  supplied 
with  alcohol.  Acetic  acid  is  also  a  by-product  of  yeast  fer- 
mentation, and  is  often  found  in  the  stomach-contents  which 
contain  an  excessive  quantity  of  free  HCl. 

The  acetic  acid  may  be  detected  by  its  peculiar  odor;  or 
the  distillate  may  be  tested  by  exact  neutralization  with  soda 
solution,  the  acetate  formed  producing  a  blood-red  color  in  a 
dilute  solution  of  chlorid  of  iron.  This  reaction  is  not  suffi- 
ciently sensitive  to  be  often  positive  in  testing  the  gastric 
contents.  In  the  absence  of  butyric  acid,  the  reddening  of  the 
moistened  litmus  paper  held  in  the  end  of  a  tube  in  which 
some  of  the  contents  are  being  heated  may  be  attributed  to 
acetic  acid. 

(^)  Alcoholic  Fermentation. — Alcoholic  fermentation  is  due 
to  the  action  of  particular  forms  of  yeast,  which  make  alcohol 
(2C2H6O)  and  carbonic  acid  (2CO2)  out  of  glucose  (C6H12O0). 


154  DISEASES  OF  THE  STOMACH. 

This  form  of  fermentation,  accompanied  by  tlie  production  of 
acetic  acid,  tartrates,  etc.,  takes  place  in  the  stomach  not 
altotjether  reijardless  of  its  acidity.  It  is  ahnost  arrested  by 
one  per  cent,  acetic  acid,  2.5  per  cent,  lactic  acid.o. i  percent, 
butyric  acid,  or  0.2  per  cent,  free  HCl ;  and  one-half  of  these 
percentages  arrest  the  growth  and  begin  to  influence  the  action 
of  the  ferment.  In  the  stomach  the  influence  of  the  acidity 
is  almost  null. 

Yeast  fermentation  may  occurs  in  any  disease  of  the 
stomach,  accompanied  by  motor  insufifiiciency,  be  the  acidity 
of  the  contents  what  it  may.  But  the  yeast  is  most  active  in 
retention.  The  alcohol  yeasts  consume  oxygen,  and,  when 
this  is  not  free  in  the  fluid,  they  remove  it  from  the  sugar 
molecule.  The  fermentation  is  purest  when  air  is  excluded, 
but  the  yeast  loses  in  vitality.  The  by-products  are  formed 
in  greatest  quantity  when  the  yeast  begins  to  degenerate  and 
to  die.  The  following  equations  represent  this  deoxidation 
process : 

CgH.A  =  Celli^O,  +  4(0)  =  2C,HgO  +  2CO,. 

Dextrose,  maltose,  and  levulose  are  directly  fermentable. 
Cane-  and  milk-sugar  are  first  converted  into  one  of  these 
substances  by  a  ferment  produced  by  the  yeast.  Starch 
must  first  be  converted  into  maltose  or  dextrose  by  a  dias- 
tatic  ferment  or  by  acids. 

Alcohol  may  be  detected  by  adding  to  the  filtered  contents 
a  few  drops  of  saturated  solution  of  iodin  in  a  solution  of 
iodid  of  potash  in  distilled  water,  and  by  dropping  in  a  solu- 
tion of  caustic  potash  until  the  brown  coloration  entirely 
disappears.  The  test-tube  is  then  placed  in  a  vessel  contain- 
ing hot  water,  and  both  are  allowed  to  cool  slowly.  After  a 
few  hours  a  yellow  precipitate  of  iodoform  falls,  which  may 
be  recognized  by  its  odor  and  by  the  regular  hexagonal 
crystals.  Acetone  gives  the  same  reaction.  Or  the  alcohol 
may  be  extracted  from  the  filtrate  by  alcohol-free  ether,  and 
the  test  made  with  Lieben's  reagent. 

Putrefaction. — Putrefaction  is  a  reduction  process.  It  is 
due  chiefly  to  anaerobic  bacteria,  and  to  such  as  extract  their 
oxygen  from  the  chemical  compounds  of  the  culture  soil, 
from  the  fats  and  the  albumins.  The  products  of  this  germ 
reduction  are  not  so  simple  as  those  of  ordinary  decom- 
position, which  is  an  oxidation  process.  These  reduction 
bacteria,  which  produce  stinking  products,  are  not  uncommon 
in  pronounced  degrees  of  motor  insufficiency. 

Putrefaction  may  be  accompanied   by  the  formation  of  a 


THE   BACTERIOLOGICAL    SIGNS.  1 55 

number  of  gases — NH3,  HoS,  N,  PH3,  CH4,  etc.;  a  number 
of  acids — butyric,  acetic,  formic,  lactic,  oxalic,  etc.;  a  number 
of  basic  substances — leucin,  tyrosin,  skatol,  ptomains,  toxal- 
bumins,  etc.;  and  a  number  of  ammoniacal  compounds.  The 
acids  may  be  combined  with  organic  bases. 

The  formation  of  HoS,  which  seldom  occurs  in  cancer,  and 
only  in  some  of  the  cases  of  retention,  is  the  most  important 
diagnostic  product  of  gastric  putrefaction.  The  H2S  is 
formed  by  reduction  of  the  organic  sulphur-containing  com- 
pounds. It  may  also  be  formed  by  reduction  of  the  sulphates, 
when  it  has  no  pathological  significance.  It  is  found  in 
benign  retention,  regardless  of  the  HCl  and  lactic  acid  percent- 
ages, after  a  diet  rich  in  the  organic  sulphur  compounds.  A 
number  of  germs  which  find  their  way  into  the  stomach  may 
produce  it,  and  among  these  germs  is  the  bacillus  coli  com- 
munis (Lesage,  Strauss).  It  may  be  detected  by  its  odor  or 
by  means  of  alkaline  acetate  of  lead.  The  lead  papers  are 
made  by  saturation  in  an  alkaline  solution  of  sugar  of  lead. 
The  paper,  previously  wet  in  an  alkaline  solution,  is  hung 
free  in  a  stoppered  bottle  containing  the  gastric  contents  ; 
and,  after  a  variable  interval,  it  becomes  brownish-black. 
If  the  action  be  too  prolonged,  the  white  sulphate  of  lead 
may  be  formed,  and  the  re'kction  may  be  no  longer  apparent. 
Or  the  sugar-of-lead-cotton  method  of  Schrank  may  be  used. 

Putrefaction  without  HoS  formation  may  be  recognized  by 
the  stinking  odor  of  the  contents,  and  rarely  occurs  in  the 
human  stomach  except  in  retention.  Leucin,  tyrosin,  indol, 
and  similar  putrefaction  products  maybe  formed  in  the  stom- 
ach when  this  organ  contains  pancreatic  juice  which  has  been 
regurgitated  through  the  pylorus,  or  which  has  found  its  way 
into  the  stomach  through  a  pancreo-gastric  fistula.  Nearly 
all  the  germs  of  putrefaction  are  gas-builders,  and  live  prefer- 
ably on  the  carbohydrates  when  the  stomach  contains  them, 
although  fermentation  and  putrefaction  may  coexist.  Con- 
sequently, gastric  putrefaction  is  conditioned  by  the  existence 
of  retention  and  by  the  presence  of  albuminous  food  and 
putrefactive  germs.  Putrefaction  is  increased  by  albumin 
digestive  products,  by  fermentable  matter,  by  small  quantities 
of  hydrochloric  and  lactic  acids,  and  by  pancreatic  juice. 

4.  Qas=formation. — A  number  of  gases  are  formed  in  the 
stomach  by  fermentation  and  putrefaction  ;  but  the  flatulency 
thus  produced  can  not  be  distinguished  by  the  physical  ex- 
amination and  the  subjective  symptoms  from  flatulency  pro- 
duced in  other  ways.  Clinically,  it  is  impracticable  to  measure 
the  exact  quantity  of  gas  in  the  stomach,  and  to  determine  by 


156  DISEASES  OE   THE   STOMACH. 

its  chemical  analysis  whether  we  have  to  deal  with  swallowed 
air,  with  chemically  generated  gas,  or  with  gas  formed  by 
germs.  The  most  rapid  and  the  easiest  method  is  to  make  a 
test  of  the  gas-forming  power  of  the  contents  of  the  stomach, 
whenever  and  however  obtained.  For  this  purpose  the 
vomit  or  the  contents  removed  during  digestion  and  during 
the  period  of  repose  of  the  stomach  may  be  used  ;  but  in 
retention  the  contents  removed  before  breakfast  in  the  morn- 
ing should  be  preferred. 

The  gas-formation  is  dependent  upon  the  composition  of 
the  medium  or  soil.  Peptones  and  other  digestive  products 
increase  it,  and  it  does  not  occur,  at  least  to  a  notable 
extent,  without  carbohydrates.  Consequently,  on  account 
of  the  possible  exhaustion  of  the  nutritive  material  in  the 
contents,  dextrose  and  peptones  should  be  added  to  the  tube 
cultures. 

The  cause  of  the  gas-formation  in  the  tubes  is  a  living 
germ.  The  filtrate  does  not  produce  it.  The  sterilized 
precipitate  added  to  the  filtrate  is  also  inactive.  The  un- 
filtered  contents  should  always  be  employed  in  the  tests. 
In  the  three-layer  contents  of  retention,  the  gas  production 
is  most  active  in  the  bottom  layer  containing  the  numerous 
germs. 

The  activity  of  the  gas-formation  is  dependent  on  the 
vitality  and  on  the  number  of  the  germs  which  accumulate 
in  the  stomach.  Gas-formation  is  moderate  in  stagnation, 
and  often  does  not  begin  in  the  tubes  until  the  end  of  one  to 
four  days.  Flatulency  is  liable  to  be  one  of  the  symptoms  in 
all  the  diseases  of  the  stomach  accompanied  by  stagnation ; 
but  in  retention  the  gas-formation  is  active  and  rapid,  and 
often  the  tube  is  nearly  full  of  gas  at  the  end  of  twenty-four 
hours.  This  is  an  important  sign  of  retention,  whether  it 
be  due  to  myasthenia  or  to  obstruction. 

Gas-formation  is  not  prevented  by  the  hydrochloric  or 
lactic  acidity  of  the  contents ;  consequently,  it  occurs  in 
both  benign  and  malignant  retention.  It  is  impossible  to 
say  whether  the  excessive  secretion  favors  gas-formation  or 
whether  the  e.xcessive  secretion  is  a  result  of  irritation.  The 
germs  seem  to  be  virulent  forms  adapted  to  the  acid  medium. 
They  progressively  neutralize  the  cultures  acidified  with  HCl, 
again  become  very  active  on  the  exhaustion  of  the  HCl,  and 
finally  degenerate  and  become  very  sensitive  to  the  anti-fer- 
mentative influence  of  the  acid.  In  estimating  the  diagnostic 
value  of  the  fermentation  tests,  the  diet  of  the  patient  should 
be  taken  into  account.     A   meat  or  proteid  diet  may  almost 


THE  BACTERIOLOGICAL    SIGNS.  1 57 

completely  arrest  it,  unless  putrefaction  occurs  ;  but  the  gas- 
forming  fermentation  recommences  with  the  resumption  of  a 
mixed  diet.  A  diet  rich  in  carbohydrates  increases  the  fer- 
mentation. The  test  should  be  made  while  the  patient  is  on  a 
mixed  diet,  is  taking  no  germ-destroying  drugs,  and  is  em- 
ploying no  remedies  to  control  the  fermentation.  The  vitality 
of  the  germs  and  the  degree  of  stagnation  or  of  retention 
will  thus  be  displayed  most  clearly. 

The  fermentation  test  may  be  made  by  using  a  Dunbar 
tube,  a  urine  saccharometer,  a  Botkin  bottle,  or  the  stoppered 
test-tube  of  Moritz.  The  apparatus  of  Moritz  is  simple, 
easily  cleaned,  and  readily  filled.  An  ordinary  test-tube  is 
fitted  with  a  perforated  rubber  cork.  Through  the  perfora- 
tion a  glass  tube,  which  is  bent  at  two  right  angles  or  in  a 
half  circle,  passes  to  the  interior  of  the  test-tube.  The 
sterilized  test-tube  is  filled  with  the  well-mixed,  unfiltered, 
and  sweetened  contents  containing  peptones  or  albumoses, 
the  cork  is  pushed  in,  and  the  glass  tubing  is  thereby  filled 
with  the  displaced  contents.  The  apparatus  is  inverted  in  a 
beaker  and  placed  in  the  thermostat  at  37°  C.  The  gas,  as 
it  forms,  collects  in  the  test-tube.  The  mixture  of  gases 
may  be  analyzed  chemically,  but  the  quantity  and  the  rapidity 
of  its  formation  have  a  much  greater  diagnostic  significance 
than  has  the  composition  of  the  mixture  of  gases.  Some 
information  as  to  the  nature  of  the  germ-growth  may  be 
obtained  by  examining  a  hanging  drop  prepared  from  the 
contents  of  the  test-tube,  and  by  comparing  the  result  with 
the  predominant  forms  of  germs  found  in  the  contents  soon 
after  their  removal  from  the  stomach. 

The  other  products  formed  by  germs  in  the  stomach  have 
no  diagnostic  value.  The  study  of  the  toxicity  of  the  con- 
tents is  of  great  interest  in  the  pathology  of  the  stomach, 
and  the  bacteriological  examination  is  a  fruitful  field  for  orig- 
inal research.  The  ordinary  methods  of  bacteriology  may 
be  readily  modified  so  as  to  meet  the  special  requirements. 


I  58  DISEASES  OF  THE  STOMACH. 

CHAPTER  V. 
THE  ANATOMICAL  SIGNS. 

The  direct  anatomical  sii^ns  of  the  diseases  of  the  stomach 
are  very  few.  They  may  be  found  in  the  vomit,  in  the  ex- 
pressed contents  after  a  test-meal,  ancF  in  the  water  used  to 
wash  out  the  stomach.  These  anatomical  signs  are  blood, 
epithelia,  leukocytes,  pieces  of  the  mucous  membrane,  and 
small  fragments  of  neoplasms. 

The  presence  of  blood  in  the  contents  or  in  the  washings  of 
the  stomach  may  very  readily  lead  to  false  conclusions.  A 
small  quantity  signifies  very  little  (unless  it  is  present  per- 
sistently or  very  frequently),  and  may  be  due  to  retching,  to 
the  introduction  of  the  tube,  to  a  temporary  or  a  chronic  con- 
gestion. Gastric  hemorrhage  occurs  also  in  severe  anemias 
and  in  cirrhosis  of  the  liver.  But  the  hemorrhagic  diseases 
of  the  stomach  are  ulcer  and  carcinoma.  Small  quantities  of 
blood  are  often  found  mixed  with  mucus  in  cases  of  gastritis, 
and  this  occurs  so  frequently  as  to  be  of  some  diagnostic 
value. 

If  the  macroscopic  and  microscopic  examinations  of  the 
contents  do  not  make  the  presence  of  blood  clear,  it  is  neces- 
sary to  use  special  tests.  Spectroscopic  examination  is  not 
clinically  practicable.  The  two  best  tests  for  blood  in  the 
stomach-contents  are  those  of  Weber  and  Jaworski.  It 
should  not  be  forgotten  that  blood  may  be  eaten  with  the 
food,  or  that  iron  (as  a  drug  or  as  a  compound  of  the  food) 
may  be  swallowed. 

Weber's  test  is  a  modification  of  Van  Deen's.  To  ten  c.c.  of 
the  filtered  contents  about  three  c.c.  of  glacial  acetic  acid  are 
added,  and  the  coloring  matter  of  the  blood  is  extracted  by 
shaking  with  about  five  c.c.  of  ether.  If  blood  is  present,  the 
ether  extract  is  brownish  ;  if  the  ether  extract  is  uncolored,  there 
is  no  blood.  The  separation  of  the  ether  may  be  facilitated  by 
the  addition  of  a  few  drops  of  alcohol.  Add  to  the  brownish 
decanted  ether  extract  ten  drops  of  fresh  tincture  of  guaiac 
and  about  20  drops  of  old  spirits  of  turpentine  or  a  small 
quantity  of  peroxid  of  hydrogen.  After  \'igorously  shaking 
the  mixture  for  a  while  it  becomes  dark  blue  if  blood  is  pres- 
ent. If  there  is  no  blood  present,  the  mixture  often  becomes 
reddish-brown  with  a  tinge  of  green.  When  the  reaction  is 
not  clear,  a  little   water  should  be  added,  and   the  coloring 


THE  ANATOMICAL    SIGNS.  I  59 

matter  extracted  with  chloroform.  If  blood  is  present,  the 
chloroform  extract  is  colored  blue. 

The  iron  test  of  Korcynski  and  Javvorski  is  made  in  the 
following  manner  :  A  small  piece  of  the  colored  and  sus- 
pected sediment  is  placed  in  a  porcelain  capsule,  with  a  pinch 
of  chlorate  of  potash  and  one  or  two  drops  of  concentrated 
HCl,  and  is  slowly  and  gently  heated  to  drive  off  the  chlorin. 
The  procedure  is  repeated,  after  the  addition  of  another  drop 
of  HCl,  until  the  residue  of  evaporation  is  decolorized.  The 
addition  of  one  drop  of  a  one  per  cent,  solution  of  potassium 
ferrocyanid  gives  a  Prussian-blue  color  if  blood  is  present. 

In  the  morning  washings  of  the  normal  stomach  are  found 
a  few  single  cylindrical  cells,  and,  rarely,  a  few  lymphocytes. 
If  the  fasting  stomach  contain  free  hydrochloric  acid,  which 
is  a  pathological  sign,  the  spiral  bodies  of  Jaworski  and 
groups  of  the  nuclei  of  leukocytes  may  often  be  found.  In 
gastritis  with  excessive  secretion  these  cell  nuclei  are  num- 
erous, and  are  mixed  with  the  mucus,  with  the  chief  cells,  and 
with  mononuclear  leukocytes.  In  asthenic  and  atrophic  gas- 
tritis no  spiral  bodies  are  found,  and  no  nuclei  of  cells  the  pro- 
toplasm of  which  has  been  digested,  but  numerous  cylindrical 
cells  and  mononuclear  leukocytes  and  sometimes  beaker  cells. 
Rarely,  groups  of  cancer  cells  are  detected.  In  suppurative 
gastritis  and  in  perigastric  abscess,  large  numbers  of  poly- 
nuclear  leukocytes  in  the  morning  washings  or  in  the  vomit 
may  reveal  the  nature  of  the  trouble. 

Exfoliated  pieces  of  the  mucous  membrane  are  sometimes 
found  in  the  morning  washings,  and  this  anatomical  sign  is 
most  frequent  in  ulcerative  gastritis  (erosions).  Pieces  of  the 
mucous  membrane  or  of  tumors  may  sometimes  be  found  in 
the  expressed  contents,  having  been  scraped  off  by  the  tube. 
This  regrettable  accident  occurs  very  rarely  when  the  velvet- 
eye  tube  is  used,  but  the  little  fragments  should  always  be 
searched  for  in  the  contents,  and  should  be  utilized  for  diag- 
nostic purposes.  The  fragments  rarely  extend  through 
the  glandular  layer,  but  sometimes  do  so,  and,  when  hard- 
ened, cut,  stained,  mounted,  and  examined  with  the  micro- 
scope, may  give  the  anatomical  diagnosis  in  a  manner  which 
leaves  no  room  for  doubt ;  but  it  should  be  remembered 
that  a  normal  piece  of  the  mucous  membrane  does  not  ex- 
clude anatomical  disease  of  another  part  of  the  stomach,  and 
that  different  forms  of  gastritis  may  coexist  in  the  same 
stomach.  The  functional  signs  must  make  clear  the  predomi- 
nant features  of  the  inflammation,  which  may  be  asthenic  or 
hypersthenic.  Gastritis  may  also  be  a  complication  of  ulcer 
or  of  cancer. 


l6o  DISEASES  OF  THE  STOMACH. 

Bile  and  pancreatic  juice  are  sometimes  found  in  the  con- 
tents, whether  vomited  or  removed  after  a  test-meal,  and  in 
the  morning  washings  before  breakfast.  This  may  occur  when 
the  stomach  is  normal.  Pathologically,  the  regurgitation  of 
bile  may  recur  persistently,  and  this  would  make  obvious  the 
easy  passage  of  the  pylorus  and  suggest  the  possibility  of 
an  obstruction  of  the  duodenum  below  the  opening  of  the 
common  duct;  but  under  such  circumstances  it  should  not 
be  concluded  that  the  pylorus  is  not  the  seat  of  an  anatomical 
disease,  for  the  pylorus  may  remain  patent,  like  a  rigid  tube, 
in  cancer,  in  cases  of  ulcer,  and  in  cicatricial  deformity. 

The  anatomical  or  dynamic  or  exact  nature  of  a  disease  of 
the  stomach  may  often  be  made  plain  by  the  results  of  treat- 
ment, even  when  all  other  signs  fail  to  clear  away  the  ob- 
scurity. This  constitutes  the  therapeutic  diagnostic  test, 
which  is  applicable  to  both  the  primary  and  the  secondary 
diseases  of  the  stomach.  The  principles  of  the  test  are  very 
simple.  If  the  h\'pothetical  diagnosis  be  correct,  certain 
results  should  be  obtained  by  a  particular  method  of  treat- 
ment, which  would  not  give  the  same  results  in  another 
disease  ;  or  the  effects  of  treatment  may  be  better  or  may 
be  worse  than  would  be  obtained  if  the  hypothetical  diagnosis 
were  true. 


SECTION    III. 
GENERAL  MEDICATION* 


The  revelations  of  the  diagnostic  methods,  together  with 
our  knowledge  of  the  genesis  and  evolution  of  the  diseases 
of  the  stomach,  furnish  the  indications  to  be  met  by  medica- 
tion. Corresponding  to  the  modern  methods  of  diagnosis 
are  the  modern  methods  of  treatment.  The  more  accurate  and 
complete  knowledge  of  physiology,  of  pathology,  and  of  the 
action  of  remedies  has  increased  our  ability  to  do  good  or  to 
avoid  doing  harm.  The  pathology  of  the  stomach,  it  is  true, 
seems  to  have  a  greater  charm  for  the  lover  of  research  than 
has  the  treatment  of  its  diseases  ;  but  the  interest  of  the 
patient  begins  with  the  medication  intended  to  cure  or  to 
give  relief. 

The  combination  of  remedies  to  meet  the  special  indica- 
tions of  the  particular  diseases  will  be  considered  in  Sections 
IV  and  V.  The  general  medication  consists  in  the  use  of 
remedies  suggested  by  the  condition  of  the  patient  and  by  the 
information  given  by  the  various  diagnostic  methods.  The 
subject  will  be  discussed  under  the  following  divisions  : 

1.  Digestive  hygiene. 

2.  Diet. 

3.  Physical  remedies. 

4.  Symptomatic  treatment. 

5.  Physiological  treatment. 

6.  Bacteriological  treatment. 

7.  Chemical  treatment. 

All  curative  treatment  demands  the  removal  or  the  control 
of  the  cause  of  the  disease.  This  general  principle  of  thera- 
peutics has  a  very  extensive  application  in  the  treatment  of 
the  diseases  of  the  stomach  ;  for  a  large  number  of  these 
diseases  are  secondary,  and  the  particular  cause  or  causes  of 
the  primary  diseases  are  often  revealed  by  the  clinical  history. 
A  man's  stomach  is  no  better  and  no  worse,  as  a  rule,  than 
he  himself  makes  it. 

'^  161 


1 62  DISEASES  OF   THE   STOMACH. 


CHAPTER  I. 
DIGESTIVE  HYGIENE. 

Digestive  hygiene  should  begin  at  birth  and  continue  with- 
out a  break  throughout  life.  In  this  manner  the  primary- 
diseases  of  the  stomach  could  be  prevented  and  life  be 
made  longer,  more  useful,  and  more  comfortable.  A  strong 
stomach  is  not  only  a  valuable  possession,  but  it  is  a  preven- 
tive against  disease,  and  good  digestion  often  decides  the 
final  result  of  a  struggle  against  a  dangerous  disease.  Diges- 
tive hygiene  consists  in  giving  to  the  stomach  proper  pro- 
tection, proper  repose,  proper  exercise,  and  proper  work 
to  do  at  regular  periods.  The  history  of  the  human  stom- 
ach is,  ordinarily,  a  long  story  of  abuse,  and  pathologists 
rarely  find  a  healthy  stomach  when  the  patient  has  died  after 
the  middle  of  life.  However  important  digestive  hygiene 
may  be  in  the  prevention  of  disease,  it  is  absolutely  essential 
to  the  cure  of  the  diseases  of  the  stomach. 

In  the  general  management  of  the  diseases  of  digestion 
there  is  nothing  more  essential  than  a  suitable  environment — 
physical,  moral,  and  social.  These  patients  are  very  sensi- 
tive to  cold,  and  become  very  languid  and  bilious  in  warm 
climates.  Their  bodies  magnify  every  change  of  tempera- 
ture. As  a  general  rule,  a  moderately  cold,  dry  location,  of 
medium  elevation,  is  very  suitable,  giving  fresh  air  and  sun- 
shine and  permitting  outdoor  life.  The  abdomen  sliould  at 
all  times  be  well  protected  by  the  clothing,  and  left  free  to 
enjoy  unimpeded  the  movements  of  the  diaphragm. 

The  moral  atmosphere  is  magnified  in  its  gloom  and  de- 
creased in  its  brightness  by  the  delicate  senses  of  these 
patients.  The  mind  is  particularly  sensitive  to  the  dark  colors 
of  life.  There  is  nothing  more  depressing  or  injurious  to 
such  patients  than  the  companionship  of  pessimists.  The 
moral  atmosphere  should  be  sustaining,  dissipating  forebod- 
ings and  inspiring  contentment,  hope,  and  courage. 

The  social  atmosphere  is  another  element  of  help  or  of 
injury.  The  slavery  of  the  social  life  ma\'  offset  all  remedial 
influences.  The  performance  of  social  duties  under  strain  or 
exhausting  excitement  may  leave  no  energy  for  digestion. 
It  is  often  essential  to  place  those  suffering  from  a  disease  of 
the  stomach  where  they  can  be  free  and  can  get  rest  and 


DIGESTIVE  HYGIENE.  1 63 

adhere  strictly  to  a  proper  diet.     In  these  respects  treatment 
in  a  sanitorium  presents  many  advantages. 

Rarely  is  the  stomach  injured  by  non-penetrating  wounds 
of  the  abdomen;  but  diseases  of  the  stomach,  particularly 
ulcer,  may  be  caused  by  traumatism — by  a  blow  or  by  re- 
peated or  prolonged  and  strong  compression.  In  this 
manner  disease  of  the  stomach  is  sometimes  produced  in 
shoemakers  and  in  others  who  use  the  abdomen  for  holding 
objects  or  instruments  in  position ;  but  more  frequently  the 
movements  of  the  stomach  are  impeded  or  the  stomach  is 
displaced  by  prolonged  compression  and  constriction  of  the 
waist.  In  this  respect  modern  fashions  are  a  curse  to  women. 
During  the  treatment  of  the  diseases  of  the  stomach,  the 
action  of  these  causes  of  disease  must  be  excluded  and  the 
stomach  be  protected  against  external  injury  and  compres- 
sion. This  hygienic  rule  is  imperative  during  the  digestive 
period. 

"  A  person  digests  as  much  with  his  legs  as  with  his  stom- 
ach," wrote  Chomel.  Exercise  facilitates  nutrition,  increases 
the  bodily  waste  and  needs,  promotes  the  appetite,  and,  under 
proper  conditions,  is  an  aid  to  digestion.  The  healthy  manual 
laborer  awaits  with  impatience  the  hour  of  his  meal,  and 
eats  all  the  more  on  account  of  his  hard  work ;  but  if  he 
becomes  greatly  fatigued,  the  appetite  is  lost.  Sedentary 
habits  may  cause  disease.  On  these  points  there  is  no  differ- 
ence of  opinion. 

When  there  is  a  serious  disease  of  the  stomach  the  matter 
is  not  so  simple,  and  the  prescribing  of  even  moderate 
exercise  during  the  period  of  digestion  may  be  a  grave  error. 
Exercise  creates  a  new  demand  for  nutriment,  and  is  bene- 
ficial on  the  condition  that  this  demand  be  met  easily  and 
without  injury.  Patients  with  diseased  stomachs  are  often 
unable  to  do  this. 

The  action  of  exercise  on  the  functions  of  the  healthy 
stomach  during  digestion  is  positive.  Moderate  exercise 
hastens  digestion,  the  stomach  completes  its  evacuation  a 
little'  earlier,  digestive  products  do  not  accumulate  in  the 
stomach,  the  acidity  of  the  contents  is  normal,  and  the 
movements  of  the  intestines  are  more  active.  Violent  exer- 
cise and  hard  labor  are  more  decided  in  their  action  and 
the  acidity  of  the  contents  is  ordinarily  below  normal. 
In  health  it  makes  little  difference  whether  a  person  take 
moderate  exercise  or  rests,  for  neither  is  likely  to  derange 
digestion.     Rest,  in  health,  increases  the  acidity  of  the  con- 


164  DISEASES  OF   THE   STOMACH. 

tents,  the  digestive  products  accumulate  in  the  stomach,  and 
the  motor  function  is  less  active  than  during  moderate  exer- 
cise.    In  sleep  these  variations  are  greater  than  in  rest. 

The  influence  of  exercise,  of  rest,  and  of  sleep  is  much 
greater  in  the  diseases  of  the  stomach  than  in  health,  and  no 
rule  can  be  formulated  which  is  applicable  to  all  these  diseases. 
Individualization  is  the  best  plan. 

The  gastroneurasthenic  should  rest  after  his  meals;  for 
otherwise  what  is  needed  by  the  stomach  may  be  used  by 
other  parts  of  the  body  and  b\'  the  mind.  The  weak  and  the 
nervous  should  rest  both  before  and  after  their  meals,  and  the 
greater  the  weakness  and  the  irritability,  the  more  stringent 
should  be  the  rule. 

Myasthenic  patients  may  or  may  not  demand  rest.  If 
the  myasthenia  is  not  of  a  high  grade  (complete  evacuation 
between  meals)  and  if  the  organ  has  not  been  overloaded, 
the  erythrism  of  the  nervous  system  produced  by  exercise 
may  be  an  aid  to  digestion  ;  but  observation  proves  that  the 
highly  myasthenic  stomach  commonly  empties  itself  soonest 
under  the  gentler  influence  of  repose.  E.xercise  and  the 
erect  position  increase  the  motor  insufficiency,  and  may 
produce  complete  retention  and  an  acute  attack  of  pain,  nau- 
sea, and  vomiting.  In  all  conditions,  the  digestion  of  a 
heavy  meal  should  be  begun  with  half  an  hour's  rest;  con- 
sequently, we  almost  invariably  prescribe,  in  myasthenia,  rest 
half  an  hour  before  and  at  least  one  hour  after  meals,  and 
allow  the  exercise,  in  keeping  with  the  individual  indica- 
tions, to  be  taken  when  the  heavier  work  of  digestion  is 
over,  and  preferably  in  the  open  air.  Some  fondly  imagine 
that  they  obey  the  laws  of  hygiene  by  promenading  in  their 
apartments  or  places  of  business.  The  exercise  during  the 
intervals  of  digestion  should  never  produce  greater  fatigue 
than  can  be  completely  dissipated  by  twenty  minutes  of  rest. 

In  many  of  the  anatomical  diseases  rest  during  digestion  is 
advisable.  Gastroptosis,  ulcer,  hypersthenic  gastritis,  ad- 
vanced carcinoma,  and  all  diseases  of  the  stomach  accom- 
panied by  irritability  of  the  mucous  membrane  or  by  emacia- 
tion and  loss  of  strength,  should  be  treated  by  repose,  which 
should,  in  severe  cases,  be  absolute. 

The  use  of  the  voice  immediately  after  meals  is  no  less  in- 
jurious than  may  be  that  of  the  muscles.  The  digestive  tube 
is  deranged  by  the  unnatural  respiration  and  by  tlie  compres- 
sion between  the  diaphragm  and  the  abdominal  muscles. 
The  abdominal  tension  is  increased  and  the  breathing  per- 
forms a  kind  of  massage.     This  rule  is   most  often  violated 


DIET.  165 

by  orators,  professors,  lawyers,  ministers,  and  singers.  There 
is  no  more  pernicious  habit  than  that  of  going  directly  from 
the  table  to  the  piano. 

Cerebral  is  no  less  injurious  than  muscular  fatigue  :  there 
are  reasons  to  believe  that  it  is  more  so.  The  overworked 
mind  does  not  cry  out  in  pain,  but  produces  insomnia — it  re- 
fuses to  stop  work.  The  strained  muscle  hurts,  and  muscular 
fatigue  brings  its  natural  cure — rest.  The  tired  man  is 
drowsy.  The  thinker  should  carefully  select  his  food,  let 
his  brain  rest  while  his  stomach  is  hardest  at  work,  and  take 
regular  and  moderate  exercise  in  the  open  air,  so  that  the 
body  will  aid  in  demanding  nutrition  and  rest  for  the  brain. 
Nothing  can  equal  the  wisdom  of  these  hygienic  rules,  except, 
perhaps,  their  perfect  uselessness.  Genius  has  long  been 
condemned  to  live  with  a  diseased  stomach  and  will  probably 
continue  so  to  do. 


CHAPTER  11. 
DIET. 

"  The  best,  the  only  good,  the  only  suitable,  diet,"  wrote 
Trousseau, "  is  the  one  which  the  patient  knows  by  experience 
best  agrees  with  him."  So  notable  has  been  the  progress  in 
the  use  of  a  diet  in  the  cure  and  prevention  of  disease  within 
the  past  twenty  years  that  this  proposition,  though  always 
false,  is  surely  no  longer  tenable.  The  healthy  man  does  not 
know  how  to  feed  himself,  and  the  diseased  man  is  far  less 
likely  to  know. 

A  rational  diet  in  the  diseases  of  the  stomach,  through  our 
more  accurate  and  complete  knowledge  of  digestion  and  nutri- 
tion, and  of  the  various  foods,  is  to-day  possible.  It  is  only 
within  the  past  two  decads  that  the  great  work  of  determining 
the  functional  power  and  the  rich  flora  of  the  diseased  stomach 
has  been  pushed  on  steadily  to  exact  practical  results.  Dur- 
ing the  same  period  a  flood  of  light  has  been  thrown  on  the 
chemical  pathology  of  nutrition,  and  on  the  utilization  of 
food  by  the  intestines  in  health  and  in  disease. 

But  in  addition  to  the  increased  knowledge  of  the  functions 
and  diseases  of  the  stomach,  and  their  relations  to  the  work 
done  by  the  intestines  and  to  the  state  of  nutrition,  we  are  also 
in  possession  of  more  accurate  knowledge  of  food.     To-day 


1 66  DISEASES  OF  THE  STOMACH. 

it  no  longer  suffices  to  order  a  fluid,  or  light,  or  easily  diges- 
tible, or  nutritious  diet ;  the  physician  must  prescribe  precisely 
and  fully  what  the  patient  should  eat.  What  is  digestible 
and  light  and  nutritious  is  unknown  to  most  persons,  who 
when  left  to  follow  blindly  their  diseased  appetites  and  dis- 
ordered sensations  are  very  likely  to  eat  too  much,  or  too 
little,  or  the  wrong  things,  or  only  a  few  articles,  and  to  be- 
come morbidly  introspective.  The  physician  should  select 
the  diet  in  accordance  with  the  indications  furnished  by  the 
individual  case,  and  should  watch  and  control  the  effects. 

The  influence  of  the  diseases  of  the  stomach  on  nutrition 
is  in  practice  a  matter  of  very  great  importance.  The  clinic 
teaches,  in  a  more  trustworthy  manner  than  experiments  on 
animals,  that  the  chemical  work  of  the  stomach,  though  very 
useful,  is  not  necessary  to  the  organism.  The  cases  in  the 
practice  of  every  physician  are  very  numerous  in  which  the 
strength  and  weight  of  the  patient  are  maintained,  in  spite  of 
loss  of  nearly  all  digestive  aid  from  the  stomach.  The  utili- 
zation of  the  albuminous  foods,  starches,  sweets,  and  fats  may 
be  complete  in  spite  of  the  chemical  inactivity  of  the  stomach  ; 
but  this  is  not  because  the  stomach  is  useless,  but  because 
the  organism  is  rich  in  resources. 

There  is  no  doubt  that  the  intestines  are  capable  of  es- 
tablishing complete  digestive  compensation  when  the  stomach 
is  insufficient,  but  on  condition  that  a  proper  diet  be  given. 
The  food  will  then  be  absorbed  in  an  assimilable  form,  and 
will  not  be  lost  by  fermentation  or  putrefaction  ;  but  this 
does  not  render  it  highly  probable,  as  is  claimed  by  some 
authorities,  that  the  inanition  in  the  diseases  of  the  stomach 
(except  in  cancer)  is  due  exclusively  to  deficient  alimentation. 
Carefully  selected  diets  may  be  well  utilized,  when  the  some- 
what indiscriminate  alimentation  of  health  is  not. 

In  a  disease  of  the  stomach  without  stagnation  or  exces- 
sive secretion  there  is  little  difficulty.  The  intestines,  if  the 
diet  be  correct,  are  fully  equal  to  the  possible  extra  work, 
when  they  are  permitted  to  do  it  without  hindrance  ;  but  where 
there  is  excessive  secretion,  duodenal  digestion  is  interfered 
with  and  the  action  of  the  saliva  is  quickly  curtailed.  The 
fat  which  reaches  the  intestines  is  well  digested  and  ab- 
sorbed, but  the  carbohydrates  and  proteids  are  partly  lost 
through  fermentation  and  putrefaction,  as  the  clinical  diet 
guides  indicate.  In  the  diseases  of  the  stomach  with  disturb- 
ance of  the  motor  function,  the  stomach  exerts  its  greatest 
power  of  doing  harm.  It  may  deliver  to  the  intestines  a  chyme 
hardly  fit  for  food,  or  it  may  reject  the  best  kinds  of  food,  or 


DIET.  167 

withhold  from  the  organism  much  of  the  food  that  is  eaten; 
but  if  care  be  taken  to  secure  delivery  to  the  intestines  of 
the  right  kind  of  food,  in  many  of  the  cases  nutrition  may 
be  well  maintained,  for  the  intestines  may  not  have  lost  their 
compensating  power.  Disease  of  the  stomach  produces 
emaciation  partly  because  the  alimentation  is  improper. 

Still,  unquestionably  in  a  large  number  of  cases,  the  chronic 
inanition  is  due  to  deficient  alimentation,  the  diet  being  too 
exclusive  or  too  reduced  in  quantity  through  fear  and 
ignorance. 

In  the  dietetic  treatment  of  the  diseases  of  the  stomach 
every  effort  should  be  made  to  keep  the  body  well  nourished  ; 
but  food  is  not  only  nutriment,  it  is  also  a  remedy.  Not  only 
must  it  meet  the  demands  of  nutrition  and  be  appropriate  to 
the  digestive  power  of  the  stomach  and  intestines,  but  its 
physiological  action  must  be  such  as  to  produce  no  harm,  or 
to  exert  a  remedial  influence,  or  to  give  the  diseased  organ 
the  appropriate  exercise  or  rest.  In  the  treatment  of  the 
diseases  of  the  stomach,  food  is  the  most  powerful  and  valu- 
able physiological  remedy.  Consequently,  a  food  should  be 
selected,  not  on  account  of  its  nutritive  value  only,  but  also 
on  account  of  its  physiological  action.  Without  a  knowledge 
of  the  uses  and  action  of  food  it  is  not  possible  to  prescribe 
a  rational  diet. 

In  the  first  part  of  this  chapter  the  rules  for  the  selec- 
tion of  a  diet  in  the  diseases  of  the  stomach  will  be  deduced 
from  the  basic  principles  of  alimentation.  In  the  second 
part  will  be  described  the  clinical  evidences  of  a  proper  diet, 
or  the  clinical  correction  or  confirmation  of  the  diet  as  given 
by  the  reasoning  of  the  physician.  The  first  is  a  deduction 
from  principles  and  from  the  subjective  and  objective  signs 
revealed  by  the  examination ;  the  second  is  the  testing  of  the 
conclusions  by  the  daily  observation  of  the  individual  case 
and  the  use  of  certain  clinical  methods  of  control. 


1.  SELECTION  OF  A  DIET  IN  DISEASES  OF  THE 
STOMACH. 

The  grand  aim  of  alimentation  in  disease  is  the  restoration 
of  the  patient  to  a  normal  state  of  nutrition  and  to  health.  The 
object,  then,  is  twofold — the  nourishment  of  the  patient  and 
the  exertion  of  a  remedial  influence  on  the  disease,  A  diet 
which  leaves  either  the  one  or  the  other  out  of  consideration 
is  fundamentally  wrong. 

The  use  of  food  as  a  remedy  does  not  mean  necessarily  the 


1 68  DISEASES  OF  THE  STOMACH. 

adoption  of  an  exclusive  diet,  or  so-called  diet-cure.  Dieting 
is  sonietinies  made  synonymous  with  slow  starvation.  A  diet 
incapable  of  maintaining  nutrition  is  a  compromise  enforced 
by  very  particular  circumstances  and  endangers  life  when 
adhered  to  for  a  long  time. 

There  is  no  general  dietetic  cure  of  the  diseases  of  the 
stomach.  Not  only  should  the  diet  be  suitable  for  the  par- 
ticular disease,  but  it  should  also  be  proper  for  the  particular 
patient.  Each  case  is  a  law  unto  itself,  and  demands  as  a 
basic  principle  of  treatment  individualization.  No  two  pa- 
tients are  alike,  either  in  the  details  of  the  disease  or  in  their 
customs,  habits,  constitution,  and  state  of  nutrition.  Neither 
is  the  dietetic  treatment  of  a  particular  disease  of  the  stomach 
fixed  and  invariable.  In  some  cases  it  is  advisable  to  change 
the  accustomed  diet,  though  it  be  improper,  slowly  and  tenta- 
tively. Changes — and  great  changes — may  be  necessary, 
but  they  should  be  gradual  and  proportionate  to  the  patient's 
power  of  adaptation.  This  matter  demands  special  attention 
when  the  patient  is  old  or  weak.  The  same  care  is  often 
necessary  in  making  radical  changes  of  the  diet,  as  in  going 
from  a  restricted  diet  to  a  more  liberal  one.  The  dietetic 
habits  and  digestive  adaptations  are  sometimes  too  rudely 
disregarded. 

Apart  from  the  management  of  exceptional  cases  there 
are  certain  general  indications  to  be  met  by  the  selection  of  a 
diet.  These  will  be  first  briefly  enumerated  and  then  more 
fully  discussed. 

1.  The  quantity  of  the  food  should  be  sufficient  to  supply 
the  needs  of  nutrition,  and  the  composition  of  the  diet  should 
approach  as  nearly  that  of  the  normal  diet  as  the  variety  of 
the  disease  of  the  stomach  will  permit. 

2.  Those  foods  should  be  selected  which  can  be  best  di- 
gested and  utilized,  and  which  are  least  likely  to  ferment  or 
decompose. 

3.  The  physiological  action  must  be  such  as  to  favor  or  to 
remedy  the  disordered  functions  and  the  anatomical  lesions. 

4.  Not  only  the  disease  of  the  stomach  but  the  state  and 
power  of  other  organs  must  be  borne  in  mind. 

5.  The  finances,  habits,  and  peculiarities  of  the  patient 
should  be  considered. 

6.  The  directions  should  be  complete  and  explicit,  and 
should  be  changed  to  meet  the  dail)'  indications. 

I .  The  quantity  of  the  food  should  be  sufficient  to  supply  the 
needs  of  nutrition,  and  the  composition  of  the  diet  should  approach 


DIET.  169 

as  nearly  tliat  of  the  normal  diet  as  the  vaiiety  of  the  disease  of 
the  stomach  ivUl  permit. 

Food  converted  into  nutriment  and  absorbed  by  the  blood- 
vessels, lacteals,  and  lymphatics  is  utilized  in  nutrition  and 
in  the  production  of  force  and  of  animal  heat.  But  what  is 
meant  by  nutrition  ?  and  how  much  food  does  the  organism 
require  ? 

The  first  theory  formulated  was  that  of  oxidation  or  com- 
bustion. Soon  after  the  great  Lavoisier  discovered  oxy- 
gen and  its  properties  were  made  known,  and  Regnault  and 
other  physiologists  studied  the  formation  of  carbonic  acid  in 
the  organism,  it  seemed  almost  sure  that  oxygen  was  carried 
by  the  hemoglobin  of  the  red  corpuscles  to  the  tissues,  and 
thus  by  combustion,  more  or  less  complete,  produced  urea, 
uric  acid,  carbondioxid,  etc.  This  seemed  to  be  a  grand 
triumph  for  biological  chemistry,  and  the  great  processes  of 
nutrition  and  respiration  were  reduced  to  a  simple  chemical 
equation.  Here  is  life  revealing  itself  in  its  essence  in  the 
form  of  a  chemical  reaction.  But  further  discoveries  only 
produced  confusion.  The  circulating  albumin  is  the  first  to 
be  destroyed,  then  the  sweets,  and  lastly  the  fats.  If  nutri- 
tion be  oxidation,  the  reverse  should  be  true;  and  such 
easily  oxidizable  substances  as  alcohol  and  pyrogallic  acid 
pass  through  the  organism  and  appear  unchanged  in  the 
urine.  Moreover,  the  quantity  of  oxygen  eliminated  in  com- 
bination with  carbon,  in  the  form  of  carbondioxid,  is  not  in 
relation  with  the  quantity  of  oxygen  introduced.  On  the 
other  hand,  with  an  excess  of  food  there  is  more  oxygen 
absorbed  and  more  urea  eliminated.  Also,  when  there  is 
quite  rapid  loss  of  body  fat,  more  oxygen  enters.  Again, 
oxygen  alone  is  without  action  on  albumins,  sweets,  and  fats. 
The  intervention  of  a  third  power  is  necessary. 

The  second  theory  is  that  of  fermentation,  and  represents 
a  transition  stage.  Nutritive  exchange  is  not  due  to  the  intro- 
duction of  oxygen  into  the  system  and  to  its  action  on  the 
circulating  nutriment,  but  is  the  result  of  the  action  of  non- 
figured  ferments  in  solution.  Not  only  digestion  but  life 
itself  is  conditioned  by  the  presence  of  ferments,  since  nutri- 
tion is  cellular  life,  and  cellular  life  makes  up  the  life  of  the 
organism  ;  but  it  is  possible  that  the  ferments  widely  dis- 
tributed in  the  organism  are  the  ferments  absorbed  from  the 
digestive  tube  and  the  associated  glands. 

The  third  and  probably  true  theory  is  that  nutrition  is  the 
life  and  the  function  of  the  cell.  Of  this  cellular  theory  there 
are  two  forms.     Some  contend  that  only  the  organized  albu- 


I/O  DISEASES  OF  THE  STOMACH. 

niin  undergoes  transformation.  In  order  that  this  view  may 
be  maintained  in  the  light  of  recent  discoveries,  its  supporters 
are  forced  to  assume  the  partial  regeneration  of  the  albumin 
by  the  utilization  of  the  analogous  carbon  and  hydrogen 
elements  of  the  sweets  and  fats.  It  is  thus  supposed  that 
nutrition  is  somewhat  like  fatty  degeneration.  This  theorj' 
is  false,  in  that  it  contains  only  a  part  of  the  truth  and  is  sup- 
ported or  supplemented  by  an  untenable  hypothesis.  The 
dissociation,  of  which  nutrition  is  the  expression,  affects  both 
the  protoplasm  of  the  cells  and  the  nutriment  in  circulation. 
Moreover,  it  is  the  circulating  nutriment  that  is  chiefly  trans- 
formed, and  for  this  reason  the  tissues  are  stable.  Let  this 
matter,  on  account  of  its  great  practical  bearing,  be  examined 
more  closely. 

The  fixed,  organized  "  protoplasm  "  is  changed  only  to  a 
very  slight  degree  in  normal  nutrition  when  the  supply  of 
nutriment  is  sufficient.  When  too  few  proteids,  for  instance, 
are  introduced,  the  quantity  of  urea  diminishes  at  once  and  if 
the  condition  continues  the  organism  begins  to  li\'e  on  itself; 
but  this  is  unphysiological,  and  normally  the  quantity  of  or- 
ganized matter  varies  but  little.  On  the  other  hand,  the  quan- 
tity of  circulating  nutriment  varies  with  the  number  of  cells 
(for  these  are  the  active  agents  analogous  to  ferments),  with 
the  rapidity  of  the  circulation,  with  the  increase  or  decrease  of 
the  temperature,  and  also  depends  on  the  degree  of  special 
activity  proper  to  each  cell. 

The  life  of  the  cell  expresses  itself  in  the  ceaseless  move- 
ments of  its  constituent  elements.  What  are  these  elements  ? 
and  what  is  the  nature  of  these  movements  ? 

The  arrangements,  association,  and  constitution  of  the 
molecules  of  a  cell  endow  it  with  its  distinctive  attributes  and 
properties.  It  is  in  this  moving  molecule  of  protoplasm  that 
the  nutritive  changes  incident  to  life  are  expressed  in  their 
simplest  form.  It  is  in  this  "  primordial  basis,"  as  Huxley 
has  happily  named  it.  that  we  shall  hope  to  detect  the  inti- 
mate nature  of  nutrition.  Simple  and  primitive  in  its  life, 
the  protoplasmic  molecule  is  complex  in  its  chemical  compo- 
sition and  its  constitution.  First  are  the  albuminous  substances, 
with  their  four  or  five  sorts  of  atoms,  C,  H,  N,S,0,and  some- 
times also  Fe  or  P  ;  then  come  also  the  ternary,  or  C,  H,  O 
compounds,  and  lastly  water  and  inorganic  salts. 

It  has  already  been  stated  that  the  interior  of  this  elemen- 
tary molecule  is  in  ceaseless  motion  ;  but  motion  presup- 
poses force,  and  the  regeneration  of  force  means  transforma- 
tion, and  transformation   predicates   a  pre-existing  substance. 


DIET.  171 

Hence,  the  existence  and  continuity  of  cellular  movements 
— or,  in  other  words,  cellular  life — is  dependent  on  the  recep- 
tion and  transformation  into  living  protoplasm,  and  on  its  util- 
ization in  the  evolution  of  heat  and  force  and  in  the  removal  of 
the  by-products,  of  material  fitted  to  undergo  these  changes. 
This  received  substance  is  called  "  nutriment,"  its  appropria- 
tion by  the  living  cell  is  known  as  "assimilation,"  and  the 
expulsion  of  the  waste  is  called  "elimination."  Assimilation, 
utilization  in  the  formation  of  heat  and  force,  and  elimination 
constitute  the  nutritive  changes,  which  are  seen  in  their 
simplest  form  in  the  proper  life  of  the  cell.  It  will  be  noted 
that  there  is  no  suggestion  of  oxidation.  The  changes  take 
place  in  the  presence  of  oxygen  as  in  the  presence  of  water, 
but  are  the  work  of  the  cell  itself. 

Apart  from  its  proper  life  the  cell  has  a  function  to 
perform  in  nutrition.  The  one  concerns  itself  alone;  the 
other  chiefly  concerns  the  organism.  This  function  is  the 
transforming  of  the  circulating  nutriment  into  force  and 
heat.  This  is,  for  the  organism,  the  important  work  of 
the  cell,  producing  by  transformation  of  the  circulating  nu- 
triment the  force  that  is  used  in  the  performance  of  function. 
It  is  widely  different  from  cellular  nutrition,  in  that  assimila- 
tion for  the  cell  by  the  cell  is  absent.  The  one  is  continuous, 
persistent,  innate  ;  the  other  is  intermittent,  variable,  pro- 
duced by  external  excitation.  Many  cells,  in  addition  to  this 
general,  have  a  special,  work.  The  power  to  perform  this 
special  function  is  furnished  by  the  organism;  but  the  per- 
formance of  each  of  these  functions  engenders  force  and 
animal  heat.  It  is  so  with  muscular  contraction;  it  is  also 
true  of  respiration,  circulation,  and  digestion,  and  of  the 
changes  undergone  by  the  nutriment  in  the  liver  and  in  the 
mesenteric  glands  before  it  reaches  the  general  circulation. 

Each  cell,  then,  of  the  body  may  be  considered  as  a  center 
for  the  transformation,  generation,  and  manifestation  of  force, 
being  endowed  with  an  impulsive  movement  which  is  its 
life.  The  new  force  is  stored  in  its  constituent  elements, 
and  is  added  to  the  unvarying  radical  and  active  force  of 
the  organism.  It  is  in  this  way  that  the  nutriment  is  util- 
ized in  nutrition,  in  the  general  meaning  of  the  word,  in- 
troducing into  the  body  the  potential  food  of  life.  But  po- 
tentiality made  active  means  transformation  and  disintegra- 
tion. This  is  true  regardless  of  the  end  of  the  generative 
power,  be  it  used  in  cellular  nutrition,  in  the  interest  of  the  or- 
ganism, or  in  the  performance  of  specialized  work.  Conse- 
quently, the  nutritive  process  includes  two  grand  results — the 


172  DISEASES  OF  THE  STOMACH. 

formation  of  tissue  and  the  evolution  of  force  and  heat ;  and  the 
food,  whicii  is  the  source,  has  two  corresponding  destinies. 
Tlie  power  of  the  organism  to  convert  food  into  some  form 
of  force  is  Hmited.  Only  one  class  of  foods — proteids — to 
even  a  limited  degree  increases  dissimilation  when  intro- 
duced into  the  circulation  in  excess.  When  more  food  is 
assimilated  than  the  organism  requires,  the  excess  is  stored  or 
organized.  Be  the  excess  proteids,  sweets,  or  fats,  the  storage 
is  practically  almost  exclusively  in  the  form  of  body  fat;  but 
be  any  organ  at  the  same  time  exercised  or  given,  within 
limits,  more  work  to  do,  that  organ  is  strengthened  and,  if  a 
muscle,  also  grows.  On  these  observed  sequences  depends 
the  possibility  of  improving  and  strengthening  the  organism 
by  a  fortifying  diet. 

In  the  dietetic  treatment  of  the  diseases  of  the  stomach 
it  is  never  an  object  to  reduce  the  weight  and  strength.  A 
starvation  or  an  insufficient  diet  may  be  made  temporarily 
necessary  by  very  special  circumstances,  and  it  may  be  very 
difficult  to  decide,  in  the  interest  of  the  patient,  how  much  is 
to  be  ultimately  gained  by  injuring  the  organism  in  order  to 
favor  the  stomach.  There  can  be  no  question  that  the  nutri- 
tion of  the  body  must  be  improved,  or  as  nearly  maintained 
as  the  disease  will  permit.  Consequently,  except  when  forced 
to  make  a  compromise,  a  primary  necessity  is  the  upholding 
or  fortifying  of  the  organism.  To  do  this  the  quantity  of 
food  that  the  organism  daily  requires  must  be  known.  But 
this  is  not  all.  To  select  the  quantity  of  food  to  be  adminis- 
tered a  knowledge  of  the  nutritive  value  of  food  in  the  par- 
ticular disease  is  also  necessary. 

The  human  organism  as  a  unit  may  be  considered  a  col- 
lection of  centers  for  the  transformation  of  force.  This  force 
comes  from  the  outer  world,  and  chiefly  in  the  form  of  poten- 
tial energy  in  the  food.  The  difference  between  the  force- 
value  of  the  food  as  it  enters  the  body  and  its  remnants  on 
their  exit,  represents  the  potential  energy  appropriated  by  the 
organism  for  the  production  of  work  and  heat.  It  is  not 
possible  to  measure  directly  the  work  done  by  the  cell  in  the 
performance  of  its  functions,  which  have  to  do  with  the  pres- 
ervation, perpetuation,  and  movements  of  the  body,  and  with 
the  mental  and  moral  life  ;  but  by  estimating  the  heat-value 
of  the  food  as  it  enters  and  leaves  the  body  we  can  obtain 
the  quantity  of  force  utilized  by  the  organism,  and  expressed 
as  so  many  units  of  heat;  or  by  observing  and  analyzing  the 
quantity  of  food  necessary  to  maintain  the  equilibrium  of  the 
body,  the  daily  needs  of  the  organism  may  be  expressed  in 


DIET.  173 

the  alimentary  principles.  The  results  thus  obtained  serve  as 
a  basis  for  the  quantity  of  food  to  be  ordered,  whether  it  be 
for  the  purpose  of  maintaining  or  of  restoring  the  balance  of 
waste  and  of  repair  or  whether  it  be  our  object  to  reduce  the 
body,  to  support  life,  or  to  force  alimentation. 

{ci)  The  Daily  Needs  of  the  Organism  estimated  in  Units 
of  Heat. — To  supply  the  daily  needs  of  the  organism  and  to 
maintain  the  balance  of  nutrition,  enough  potential  energy  in 
the  form  of  food  must  be  received  to  cover  the  consumption 
in  the  form  of  work  and  of  animal  heat.  Such  a  quantity  of 
food  represents  the  diet  of  support.  Under  such  a  regimen 
as  much  is  added  to  the  body  as  is  taken  from  it.  The  poten- 
tial energy  introduced  and  appropriated  is  exactly  equal  to 
the  work  and  heat  developed.  The  nutritive  value  of  this 
merely  supporting  diet  represents  the  daily  needs  of  the 
organism,  and  affords  for  it  an  exact  measure. 

The  amount  of  potential  energy  consumed  by  the  body 
when  at  rest  may  be  called  the  biological  coefficient.  The 
voluntary  movements  by  which  the  body  is  placed  in  relation 
with  external  objects  is  not  included  in  this  conception.  The 
store  of  potential  energy  is  only  drawn  upon  for  internal  work 
and  for  the  supply  of  animal  heat. 

The  quantity  of  potential  energy  necessary  to  maintain  the 
dynamic  equilibrium  of  the  body  in  repose  is  dependent  on 
the  number  of  the  noble  elements  of  the  body,  and  on  their 
work  in  the  maintenance  of  life.  Each  living  cell  is  in  con- 
tinuous motion,  and  motion  is  an  expression  of  transformed 
or  liberated  force.  When  these  cells  are  more  numerous,  the 
consumption  of  potential  energy  is  greater. 

Not  only  the  number  of  cells,  but  also  the  activity  of  the 
cellular  protoplasm,  which  varies  at  different  ages,  must  be 
considered.  The  adult  requires  more  food  than  the  child, 
and  the  needs  of  the  body  diminish  with  the  degeneration  of 
old  age.  The  weight  of  the  body  is  no  measure  of  this 
need.  The  greater  part  of  the  body  framework,  the  deposit 
of  fat  and  other  tissues  endowed  with  little  activity,  neither 
consume  nor  liberate  much  force  in  their  existence.  A  man, 
when  emaciated,  consumes  less  than  when  well  nourished, 
because  the  number  of  noble  elements — of  cells  which  do  a 
work  for  the  organism — is  diminished.  The  same  individual 
on  becoming  fat,  needs  and  consumes  little  more,  because  the 
fat  cells  have  no  active  altruistic  work  to  do. 

The  second  factor  of  the  biological  coefficient  is  the  poten- 
tial energy  consumed  by  the  circulation,  respiration,  and  the 
cells  concerned  in  digestion  and  nutrition.    One  part  is  repre- 


174  DISEASES  OF  THE  STOMACH. 

sented  by  muscular  work  and  the  other  by  glandular  activity, 
and  both  are  under  the  control  of  the  most  highly  endowed 
dynamic  cells  of  the  body. 

The  smaller  the  mass,  the  greater  is  its  relative  surface 
area.  Consequently,  small  animals  lose  more  heat  in  propor- 
tion to  their  size  than  larger  ones  in  a  similar  environment. 
The  same  law  obtains  with  adults  of  different  size,  and  applies 
also  to  the  variations  due  to  the  growth  of  the  infant  into 
manhood.  The  consumption  and  the  cellular  activity  are 
relatively  greater  in  order  to  meet  the  proportionate  by  greater 
loss.  Nothing  can  be  more  important  than  the  protection  of 
the  body  against  the  loss  of  heat  in  emaciated  and  in  adynamic 
conditions. 

The  moisture  of  the  climate  is  without  influence,  inasmuch 
as  the  diminished  loss  by  evaporation  is  compensated  by  the 
increased  loss  by  radiation  and  conduction.  Heat  pro- 
duction in  the  properly  protected  body  in  repose  is  constant. 
This  is  regulated  through  the  nervous  system  by  which 
heat  production,  established  through  the  law  of  survival  at  a 
minimum,  is  transmitted  as  a  fixed  peculiarity  embodied  in  a 
biological  law. 

The  biological  coefficient  no  longer  represents  the  total 
work  of  the  organism,  as  soon  as  the  state  of  repose  is 
broken.  The  amount  of  potential  energy  consumed  is  in- 
creased by  the  taking  of  food  and  by  the  process  of  digestion, 
by  mental  and  muscular  work. 

The  quantity  of  nutriment  consumed  is  not  proportionate, 
as  was  once  thought,  to  the  quantity  of  food  introduced. 
The  body  is  not  a  furnace  that  burns  immediately  and  unceas- 
ingly everything  combustible  introduced  into  it.  Digestion 
requires,  through  its  muscular  and  glandular  activity,  an  addi- 
tional amount  of  activity,  which  varies  with  the  digestibility 
and  the  physiological  action  of  the  constituents  of  the  meal. 
Zuntz  estimates  that  the  amount  of  oxygen  consumed  is  in- 
creased 15  per  cent,  during  the  digestion  of  a  moderate  meal, 
and  a  man  digesting  enough  food  to  maintain  the  organism 
increases  the  consumption  for  twenty-four  hours  of  rest  and 
fasting  by  about  ten  per  cent.  The  total  production  of  animal 
heat  is  in  like  proportion  increased. 

This  principle  is  of  the  highest  practical  importance.  Mere 
excitants  of  the  alimentary  canal  destroy  potential  energy. 
Food  easily  digested  and  quickly  absorbed  produces  hardly  a 
perceptible  increase  of  nutrition  waste.  Only  by  a  correctly 
selected  diet  can  the  reduced  organism  be  restored  to  a  good 
nutritive  state.     The  introduction  of  food  increases  the  waste 


DIET.  175 

by  its  action  on  the  alimentary  canal,  and  not  directly  by 
being  itself  consumed.  A  rich  diet  may  mean  a  loss,  as  there 
is  no  luxurious  consumption.  The  excess  is  undigested,  un- 
absorbed,  or  incompletely  oxidized.  Alimentation  is  most 
economical  when  the  nutriment  introduced  is  the  exactamount 
required.  An  excess  is  stored  or  wasted,  and  when  too  little 
food  is  taken  the  body  lives  on  itself. 

Muscular  work  is  the  cause  of  the  greatest  expenditure  of 
force  above  that  of  the  biological  coefficient.  The  increased 
consumption  of  oxygen  in  very  slight  movements  and  its  de- 
mand in  strained  work  illustrate  how  close  and  great  is  the 
influence  of  muscular  work  on  the  consumption  of  potential 
energy.  Zuntz  estimates  the  daily  consumption  by  hard  work 
at  25  per  cent,  above  the  expenditure  in  repose. 

In  the  performance  of  muscular  work,  much  more  potential 
energy  is  consumed  than  is  expressed  by  the  useful  work 
performed.  Rubner's  researches  give  a  loss  of  nearly  four- 
fifths.  This  loss  is  not  a  constant  one,  and  is  not  so  great 
when  the  man  is  fresh  and  trained  to  use  his  muscles. 
Fatigue,  a  relatively  great  effort,  and  a  lack  of  training  involve 
great  loss  and  excessive  consumption. 

The  following  table  gives  in  round  numbers  the  daily  con- 
sumption by  an  adult  weighing  65  kilograms,  the  figures 
representing  looo  heat  units  : 

Rest  in  bed,  1800  Cal. ,  or  28  Cal.  per  kilo. 

In  repose,  2100  Cal.,  or  32  Cal.  per  kilo. 

In  light  work,  2300  Cal.,  or  ^iZ  Cal.  per  kilo. 

In  moderate  work,  2600  Cal.,  or  40  Cal.  per  kilo. 

In  strained  work,  3100  Cal. ,  or  48  Cal.  per  kilo. 

The  estimation  of  the  needs  of  the  organism  in  units  of 
heat  does  not  correspond  with  the  actual  uses  of  food  in  nu- 
trition. Only  a  part  of  the  food  assimilated  is  used  in  the 
production  of  heat.  Again,  although  the  end-products  of 
the  fats  and  carbohydrates  are  the  same  in  the  calorimeter 
as  in  the  body,  those  of  albumin  are  different.  The  calor- 
imetric  value  of  animal  albumin  is  5.7  Cal.,  that  of  vege- 
table albumin  is  5.6  Cal.;  but  the  nutritive  value  of  albumin 
is  represented  by  the  number  of  heat  units  liberated  by  its 
oxidation  and  conversion  into  the  compounds  which  repre- 
sent the  forms  in  which  it  is  eliminated  from  the  body,  and, 
according  to  Rubner,  is  4.2  Cal.  and  4  Cal.,  respectively,  for 
animal  and  vegetable  albumin.  The  nutritive  value  often  gm. 
of  fat  is  equal  to  23  gm.  of  albumin  or  carbohydrates;  or — 

I  gm.  albumin  or  carbohydrates  =  4. 1  Cal. 
I  gm.  fat  =   9.3  Cal. 


176  DISEASES  OF  THE  STOMACH. 

The  conversion  of  the  older  estimate  of  the  needs  of  the  or- 
ganism, in  so  man\'  grams  of  albumin,  fat,  and  carbohydrates, 
into  the  newer  calorimetric  equivalent  is  an  easy  process  of 
multiplication  ;  but  the  new  method  is  clinically  a  great  ad- 
vance on  the  old  one.  The  alimentary  principles  can,  within 
limits,  be  substituted  for  one  another,  and  in  the  treatment  of 
the  diseases  of  the  stomach  the  substitution  is  usually  and 
necessarily  made.  The  calorimetric  method  renders  a  com- 
ple.x  problem  simple  and  easy.  The  force-\-alue  of  the  diet 
is  revealed  at  a  glance,  and  it  is  quickly  seen  whether  it  is 
insufficient,  supporting,  or  strengthening. 

(/;)  The  Daily  Needs  of  the  Organism  as  represented  by 
the  Alimentary  Principles. — The  amount  of  force  daily 
needed  by  the  organism,  both  in  a  state  of  repose  and  in 
internal  and  e.xternal  activity,  can  thus  be  accurately  esti- 
mated in  units  of  heat.  The  measure  of  the  oxygen  con- 
sumed, the  difference  between  the  heat-value  of  the  food  and 
that  of  the  waste  products  eliminated,  minus  the  amount  re- 
tained and  organized  or  stored  in  the  body,  and  the  estima- 
tion of  the  heat-value  of  the  food  necessary  to  preserve  the 
body  for  a  long  period  in  nutritive  equilibrium,  have  re- 
vealed with  sufficient  precision  the  needs  of  the  organism. 
Turn  we  now  to  a  short  study  of  the  available  material  for 
the  supply  of  these  demands.  The  daily  needs  of  the  organ- 
ism must  be  supplied  by  that  which  is  of  nutritive  value  in 
the  food. 

The  value  of  the  food  to  the  organism  is  dependent  on  its 
chemical  composition,  on  the  combination  of  the  alimentary 
principles,  and  on  its  digestibility  and  utilization. 

Not  all  the  chemical  constituents  of  a  food  are  of  nutritive 
value.  A  part  ma}'  be  insoluble  in  the  digestive  fluids,  and 
may  either  become  the  food  of  micro-organisms  or  pass  into 
the  feces.  A  part  may  be  absorbed,  onlj^  to  be  eliminated 
on  account  of  its  worthlessness  in  nutrition.  A  part  may 
waste  as  much  potential  energy  in  its  digestion  and  assimila- 
tion as  it  supplies  in  its  products.  A  part  may  be  absorbed 
unchanged,  and  may  be  useful  or  essential  to  nutrition  with- 
out directly  contributing  potential  energy  to  the  organism. 
These  are  only  important  on  account  of  their  chemical  and 
physiological  action.  A  part  may  be  absorbed  after  prelimi- 
nary transformation  and  be  utilized  in  supplying  the  needed 
force  and  heat. 

Food,  then,  contains  {a)  material  which  maintains  the 
nutritive  equilibrium  and  furnishes  heat  and  force.  The  most 
important  of  the  members  of  this  class  are  the  proteids,  fats, 


DIET.  17  J 

and  carbohydrates.  Alcohol  and  the  organic  acids  are  also 
capable  of  furnishing  some  force  and  animal  heat  in  their 
consumption.  Fat  and  albuminous  foods  may  be  either  of 
vegetable  or  of  animal  origin,  and  possess  nutritive  values 
according  to  their  qualities  and  chemical  constitution.  The 
carbohydrates  are  products  of  the  vegetable  kingdom.  All 
these  foods  are  organic. 

The  second  class  contains  {b)  inorganic  compounds,  or 
mineral  matter.  The  chief  of  these  inorganic  elements  are 
H,  O,  Na,  K,  CI,  Ca,  Mg,  Fe,  Mn,  P,  and  S.  These  elements 
are  in  various  combinations  as  salts,  and  are  as  essential  to 
the  organism  as  are  the  members  of  the  first  class.  There 
exists  for  each  a  minimum  quantity,  without  which  inanition, 
and  even  death,  may  result.  These  inorganic  compounds  are 
present  in  excess  in  all  the  foods  employed  in  diet  prescrip- 
tions. This  is  not  the  case  with  water  or  common  salt ; 
these  will  receive  further  consideration. 

These  compounds  exist  in  all  three  kingdoms,  but  give  no 
force  or  heat  to  the  human  body.  Their  function  is  almost 
exclusively  a  chemical  one. 

The  remaining  compounds  {c)  are  organic,  and  owe  their 
value  to  their  physiological  action.  This  value  may  be  due  to 
their  odor  or  taste,  and  to  their  local  action  on  the  stomach 
or  intestines,  or  on  nutrition,  or  on  one  or  more  organs  of  the 
body.  Some  of  them  also  furnish  a  very  small  quantity  of 
energy,  which  may  be  consumed  in  the  work  of  the  body,  as 
the  alkaloids  and  glucosids.  This  class  exists  in  all  food 
that  is  not  insipid.  They  give  the  pleasant  odor  and  taste  to 
food.  Their  physiological  action  is  essential  to  good  diges- 
tion and  to  nutrition. 

A  fourth  part  of  the  food  {d),  important  for  its  local  physi- 
ological action,  is  the  indigestible  residuum. 

The  Uses  of  the  Albumins. — Albumin  may  be  absorbed  with- 
out having  been  transformed  by  the  digestive  ferments.  Al- 
bumins are,  however,  rarely  eaten  raw  or  in  a  fluid  state, 
except  in  milk,  and  this  fluid  rapidly  becomes  a  solid  in  the 
normal  stomach  under  the  coagulating  power  of  the  labfer- 
ment.  In  health  very  little  albumin  is  absorbed  without  trans- 
formation, although  this  may  occur  when  a  very  large  quantity 
is  eaten.  A  part  of  it  then  appears  in  the  urine,  as  also 
occurs  when  the  albumin  is  introduced  directly  into  a  vein. 

The  only  chemical  work  performed  by  the  formed  elements 
of  the  gastric  juice  is  the  digestion  of  the  albumins.  This 
transformation  is  a  progressive  one.  The  albumin  is  con- 
verted into  syntonin,  albumoses,  and  finally  peptones — which 


178  DISEASES  OF  THE   STOMACH. 

differ  from  one  another  in  their  degrees  of  solubility  and 
diffusibility  through  an  animal  membrane  and  in  their  chemi- 
cal properties.  The  transformation  is  in  all  probability  a 
change  of  the  chemical  constitution  of  the  molecule,  while 
the  chemical  composition  is  not  altered.  Recent  investigations 
would  indicate  that  the  albumin  molecule  is  split  up  into 
smaller  ones  with  the  same  chemical  composition.  Water 
here,  as  in  all  chemical  processes,  plays  an  essential  part. 
Very  little  albumin  is  converted  by  the  gastric  juice  into  true 
peptone,  the  process  not  going  further  than  the  albumoses. 
With  the  pancreatic  juice,  however,  this  is  otherwise.  The 
intermediate  compounds  are  rapidly  changed  into  the  end- 
products  of  albumin  digestion,  and  so  powerful  is  this  fer- 
ment that  a  part  of  the  peptones  may  be  decomposed,  and 
the  greater  part  of  the  potential  energy  of  the  molecule  may 
be  wasted. 

According  to  the  generally  accepted  ideas  of  Kiihne  and 
his  followers,  the  albumin  molecule  is  split  into  two  series  of 
compounds  of  different  qualities,  to  wliich  the  names  anti- 
and  hemi-albumose  and  anti-  and  hemi-peptone  have  been 
given.     The  following  diagram  represents  this  view  : 

Albumin. 


Hemi-albumose.  Anti-albumose. 

i  j 

Hemi-peptone.  Anti-peptone. 


Leucin.  Asparaginic  acid. 

Tyrosin.  Protein-chromogen. 

These  distinct  and  double  but  contemporaneous  methods 
of  division  were  first  demonstrated  by  Kiihne  in  the  diges- 
tion of  fibrin,  and  the  same  principle  has  been  shown  to  ob- 
tain for  other  forms  of  albumin,  such  as  gluten,  legumen, 
vitellin,  casein,  myosin,  etc. 

The  products  of  gastric  and  pancreatic  digestion  are  not 
the  same,  even  with  the  same  form  of  albumin.  In  the 
stomach,  albumoses  are  formed  in  far  larger  quantities.  In 
the  intestines  the  peptones  predominate. 

The  nutritive  value  of  these  products  of  albumin  digestion 
is  variable.  Consequently,  the  form  of  albumin  prescribed, 
the  location  of  its  transformation,  and  the  rapidity  of  its 
absorption  are  of  practical  importance.  This  is  most  evident 
in    disease.     In    health,  selected    and    digestible  nitrogenous 


DIET.  179 

food  is  nearly  all  absorbed,  only  three  to  five  per  cent,  being 
lost  in  the  feces.  But  the  percentage  of  utilization  varies 
widely  with  different  articles  of  food  in  the  disorders  and 
diseases  of  the  digestive  tube. 

The  greater  part  of  the  products  of  the  digestion  of  albu- 
min are  absorbed  before  the  ileocecal  valve  is  reached,  only 
about  one-fifth  reaching  the  large  bowel.  This  is  the  work 
of  the  cell,  which  pours  these  products  into  the  blood-vessels 
exclusively.     The  lymph-vessels  receive  none. 

The  products  of  the  digestion  of  albumin  are  taken  up,  on 
their  passage  through  the  wall  of  the  alimentary  canal,  by 
the  white  blood  corpuscles.  None  of  these  products  are 
received  free  into  the  serum  of  the  blood.  This  digestive 
leukocythemia  is  only  present  during  the  digestion  of  albu- 
minous foods,  when  the  number  of  white  corpuscles  in  the 
veins  is  enormously  increased.  These  products  are  absorbed 
by  the  epithelial  lining  of  the  stomach  and  intestines,  and  are 
taken  up  out  of  the  alimentary  wall  by  the  white  corpuscles 
and  reconstituted  into  albumin.  The  white  corpuscles  assimi- 
late albumin. 

All  the  products  of  the  digestion  of  albumin  down  to  the 
true  peptones  are  received  by  the  white  corpuscles  and  re- 
constituted into  cellular  protoplasm.  The  albumin  thus  be- 
comes endowed  with  life  and  loses  the  personal  identity  it 
possessed  before  digestion  and  absorption.  Out  of  this  re- 
constituted albumin  all  the  protoplasmic  cells  of  the  body 
receive  the  food  which  is  to  supply  the  wear  and  tear  of  life. 
The  albumin  of  food  is  also  used  in  other  ways,  and  reap- 
pears in  the  albuminous  constituents  of  the  secretions.  The 
casein  of  milk  is  a  product  of  cell  activity,  as  is  likewise 
hemoglobin.  The  last  is  a  synthetic  compound  of  hemo- 
chromogen  and  of  globulin.  The  mucin  is  a  compound  of 
albumin  and  of  carbohydrates  under  the  influence  of  the 
epithelial  cells.  In  like  manner  many  of  the  other  cells  build 
special  forms  of  albumin  out  of  the  albumin  of  the  food. 
The  albumins  constitute  about  one-eleventh  of  the  weight  of 
the  body,  and  nearly  one-half  of  the  total  quantity  is  con- 
tained in  the  muscular  system. 

The  dissimilation  of  albumin  is  a  complex  process,  which 
is  best  and  almost  e.xclusively  known  in  its  end-products. 
This  constitutes  the  chief  use  of  albumin,  the  disintegration 
liberating  force  and  heat  and  demanding  replacement  by 
nitrogenous  food.  It  is  only  when  the  assimilation  of  albu- 
min is  greater  than  its  dissimilation  that  the  excess  becomes 
organized. 


l8o  DISEASES  OF  THE  STOMACH. 

The  quantity  of  albumin  daily  disintegrated  by  a  well- 
nourished  person  weighing  70  kilograms  is  about  60  gm.  when 
fasting.  The  quantity  of  albumin  in  a  well-compounded  diet 
should  never  be  less  than  this  amount.  One  gm.  of  fat  is 
equal  to  about  2.4  gm.  of  albumin  or  carbohydrates,  and  the 
albumin  can,  within  a  wide  range,  be  replaced  by  and  replace 
the  other  two  large  classes  of  food  ;  but  the  caloric  value 
of  the  albumin  should  never  be  greater  than  one  third  nor 
less  than  one-sixth  of  the  caloric  value  of  the  other  two 
combined.  The  albumin  required  by  the  body  for  organiza- 
tion can  be  replaced  by  no  other  kind  of  food. 

On  an  exclusive  diet  of  lean  meat,  about  two  and  one-half 
or  three  times  as  much  albumin  as  is  disintegrated  and  elimi- 
nated from  the  body  in  hunger  (50  to  60  gm.)  is  required 
to  establish  nitrogenous  equilibrium.  The  average  quantity 
is  about  1200  gm.  of  lean  beef.  But  while  the  nitrogenous 
equilibrium  may  be  maintained  on  an  exclusively  meat  diet, 
no  increase  of  weight  and  strength  can  be  produced,  for  the 
dissimilation  becomes  greater  as  the  quantity  of  albumin  is 
increased,  and  the  equilibrium  is  re-established  b\^  more  active 
metabolism.  The  increased  ingestion  of  albumin  renders  the 
fluid  which  surrounds  the  cells  richer  in  albumin,  but  no 
albumin  is  organized  and  the  development  of  new  cells  is  not 
stimulated.  On  an  e.xclusive  nitrogenous  diet  man  neither 
fattens  nor  organizes  albumin  after  the  balance  of  nutrition  is 
established.  Consequently,  a  healthy  body  may  be  main- 
tained, but  a  weak  or  emaciated  person  can  not  be  made 
stronger.  The  first  effect  of  an  exclusive  meat  diet  is  loss 
of  weight  and  strength.  The  body  fat  is  utilized  and  burned, 
and  the  increased  albuminous  waste  is  greater  than  the  quan- 
tity of  albumin  digested  and  assimilated.  To  establish  good 
nutrition  so  large  a  quantity  of  meat  is  required  that  even  the 
most  tender  and  palatable  meats  become  disgusting.  The 
normal  excitation  of  intestinal  peristalsis  is  removed  and  the 
acidity  of  the  contents  of  the  small  intestine  disappears. 
Constipation,  putrefaction,  uric  acid  precipitation,  and  auto- 
intoxication become  the  prominent  symptoms,  and  to  prevent 
injury  the  body  must  be  placed  in  repose,  non-nitrogenous 
food  must  be  administered  with  the  meats,  and  eliminative 
treatment  must  be  employed.  Gradually,  under  rest,  laxatives, 
and  large  quantities  of  water,  the  symptoms  are  relieved  and 
the  repugnance  overcome.  Eventually,  nitrogenous  equili- 
brium may  be  established  as  more  and  more  meat  is  eaten  ; 
and  the  individual  then  becomes  stronger,  but  no  fat  or  albu- 
min is  orgfanized. 


DIET.  151 

Carbohydrates. — The  carbohydrates,  found  only  in  traces  in 
the  animal  body,  exist  chiefly  as  the  sugars,  organic  acids, 
and  starches  in  vegetable  food  and  fruit.  The  starches  must 
first  undergo  digestive  transformation  before  absorption  and 
utilization.  Some  of  the  sweets  are  already  absorbable  in  the 
form  in  which  they  are  taken  into  the  alimentary  canal. 

Starch,  when  finely  divided  and  liberated  from  its  inclosing 
capsule  of  cellulose,  is  rapidly  transformed  by  the  ptyalin  of 
the  saliva,  when  the  medium  is  alkaline,  neutral,  or  slightly 
acid,  into  soluble  starch,  erythrodextrin,  achroodextrin,  and 
maltose.  The  starch  which  escapes  salivary  digestion,  and 
the  ptyalin  products  unabsorbed  by  the  stomach,  are  delivered 
to  the  intestines  for  the  completion  of  the  digestive  transfor- 
mation by  the  diastase  of  the  pancreatic  juice.  Theoretically, 
the  end-product  of  starch  digestion  is  maltose,  but  in  the 
digestive  tube  the  transformation  rarely  goes  beyond  the  dex- 
trin stage,  maltose  being  found  rarely  and  only  in  traces  in 
the  portal  vein. 

Milk-sugar  probably  requires  and  undergoes  no  digestion. 
Cane-sugar  is  inverted  by  the  HCl  of  the  gastric  juice,  and 
also  by  the  intestinal  secretion,  Levulose,  a  digestive  pro- 
duct of  cane-sugar,  and  also  found  in  fruits  and  honey,  is 
absorbable.  The  sugars  may  nearly  all  be  absorbed  as  such, 
and  their  digestive  transformation  increases  their  absorb- 
ability and  liability  to  ferment. 

The  sugars  introduced  with  the  food  and  formed  by  the 
digestion  of  starch  are  absorbed  by  the  radicals  of  the  portal 
vein,  and  undergo  further  changes  fitting  them  for  utilization. 
If  the  analysis  of  the  stools  alone  be  taken  in  evidence,  the 
carbohydrates  are  almost  completely  digested  and  absorbed, 
when  properly  prepared  and  not  taken  in  excessive  quantity. 
But  practically  and  clinically,  both  in  health  and  in  disease,  a 
Considerable  quantity  undergoes  fermentation.  The  products 
of  fermentation  may  possess  some  nutritive  value,  and  the  slight 
acidity  of  the  intestinal  contents  produced  by  the  fermentation 
is  a  safeguard  against  albuminous  decomposition.  The  gases 
of  fermentation  interfere,  when  in  excess,  with  the  functions  of 
the  bowel,  and  the  organic  acids  may  produce  irritation  and 
inflammation. 

The  absorbed  products  of  carbohydrate  digestion  are  as- 
similated, and  are  either  stored  as  glycogen  in  the  liver,  mus- 
cles, and  white  blood  corpuscles,  or  are  burned  as  grape-sugar 
in  the  production  of  force  and  heat.  There  is  also  no  doubt 
that  the  organism  can  and  does,  in  certain  conditions,  trans- 
form the  carbohydrate  products  into  fat  to  be  stored  in  the 


1 82  DISEASES  OF  THE  STOMACH. 

body.  The  carbohydrates  diminish  nitrogenous  waste,  and, 
in  very  large  quantities,  reduce  the  daily  nitrogenous  loss 
below  that  of  tasting.  Fat  is  also  protected  by  the  carbo- 
hydrates, 240  gm.  being  isodynamic  for  this  purpose  with 
100  gm.  of  fat  taken  as  food.  The  amount  of  fat  can  be  com- 
pletely protected  if  with  lOO  gm.  of  albumin  about  600  gm. 
of  carbohydrates  are  digested  and  utilized.  If  the  quantity 
of  carbphydrates  be  increased,  the  body  may  become  fatter 
and  some  of  the  albumin  ma}'  be  organized,  but  in  order  to 
insure  the  latter  the  quantity  of  albumin  should  also  be  in- 
creased. If  fed  exclusively  on  carbohydrates  man  would 
starve,  through  the  uncovered  loss  of  albumin,  unless  carried 
off  earlier  by  the  diarrhea  and  enteritis  produced  by  excessive 
fermentation. 

Fats. — The  digestion  and  absorption  of  fat  begin  in  the  in- 
testines. In  the  stomach  only  small  quantities  of  fatty  acids 
are  normally  found,  and  are  either  introduced  as  such  or  are 
separated  from  the  triglycerid  molecule  by  bacteria — and 
possibly  by  a  special  ferment.  A  special  ferment  of  the  pan- 
creatic juice  splits  a  part  of  the  fat  into  fatty  acids  (93  per 
cent.)  and  glycerin  (7  per  cent.),  the  fatty  acids  combining 
with  alkalies  (of  the  bile,  chiefly)  to  form  soaps,  and  with 
the  aid  of  these  products,  and  of  the  bile  and  the  pancreatic 
juice,  the  remaining  fat  is  emulsified.  Only  about  one-eighth 
of  the  fat  is  decomposed,  but  the  relative  proportion  of  the 
fatty  acids  and  soaps  increases  as  the  lower  end  of  the  bowel 
is  approached.  This  is  due  partly  to  the  action  of  the  split- 
ting bacteria,  but  chiefly  to  the  rapid  absorption  of  the  emul- 
sion of  neutral  fat  by  the  epithelium  covering  the  intestinal 
follicles,  and  possibly  by  wandering  leukocytes.  The  ab- 
sorbed fat  reappears  in  the  lymph  as  neutral  fat,  and  is  util- 
ized in  the  production  of  heat,  of  force,  and  of  adipose  tissue, 
which  latter  constitutes  from  5  to  25  per  cent,  of  the  weight 
of  the  body.  No  other  tissue  is  subject  to  such  wide  quanti- 
tative variations. 

Fat  alone  is  unable  to  check  the  waste  of  nitrogenous 
tissues,  and  only  prolongs  the  period  of  starvation.  A 
fasting  man  wastes  more  than  twice  as  much  fat  as  albumin, 
but  protection  against  loss  of  fat  can  be  given  either  by 
albumin,  by  fat,  or  by  carbohydrates ;  both  a  loss  of  fat 
can  be  prevented  and  a  gain  of  fat  insured  most  economically 
by  a  judicious  combination  of  the  three  alimentary  prin- 
ciples. As  a  protective  against  loss  of  fat,  lOO  gm.  of  fat  are 
equivalent  to  about  225  gm.  of  albumin.     Large  quantities  of 


DIET.  183 

fat  can  prevent  loss  of  body  fat,  or  even  increase  its  quantity 
in  spite  of  simultaneous  albuminous  emaciation. 

The  more  fat  is  given,  other  things  being  equal,  the  more 
is  found  in  the  stools.  But  the  total  quantity  of  fat  absorbed 
increases  until  the  quantity  administered  is  about  300  gm. 
This  seems  to  be  the  limit  of  digestive  power. 

Gelatin. — Gelatin  is  a  very  valuable  force-  and  heat-produc- 
ing food.  It  is  never  organized  into  fat  or  iBesh,  and  in  very 
large  quantity  can  not  completely  cover  albuminous  waste ; 
but  with  gelatin  the  quantity  of  albumin  needed  can  be  reduced 
to  a  minimum,  even  below  the  amount  of  albuminous  waste 
during  fasting.  As  a  protector  of  body  albumin,  100  gm.  of 
gelatin  is  equivalent  to  about  35  gm.  of  food  albumin,  or  200 
gm.  of  carbohydrates.  On  the  other  hand,  gelatin  does  not 
protect  against  loss  of  fat  as  well  as  do  either  fat  or  the  carbo- 
hydrates, 100  gm.  being  equivalent  to  about  25  gm.  of  the 
dissimilated  fat  of  the  body. 

Combinations  of  the  Alimentary  Principles. — When  fats  are 
combined  with  albumins,  a  little  less  than  half  as  much  albu- 
min is  required  to  maintain  nitrogenous  equilibrium  as  in  an 
exclusively  albuminous  diet.  If,  after  the  combination  is 
found  which  in  an  individual  case  exactly  maintains  the 
nutritive  equilibrium,  more  albumin  is  given  with  a  propor- 
tionately large  quantity  of  fat,  both  albumin  and  fat  will  be 
organized  and  deposited.  If  carbohydrates  be  substituted 
for  the  fats,  increase  of  albumin  causes  a  slight  increase  in 
both  the  albumin  and  the  fat  of  the  body  ;  increase  of  both 
results  in  bodily  gain  of  flesh  and  fat.  In  protection  against 
albuminous  waste  the  carbohydrates  are  more  powerful  than 
the  fats,  but  100  gm.  of  fat  are  equal  to  240  gm.  of  carbo- 
hydrates in  the  protection  against  loss  of  fat. 

The  body  can  be  most  economically  nourished  by  a  judi- 
cious combination  of  the  three  alimentary  principles.  The 
proportion  of  the  caloric  value  of  the  albuminous  to  the  non- 
albuminous  foods,  and  of  the  fats  to  the  carbohydrates,  should 
be   I  to  3  or  5. 

The  following  average  estimates  of  the  quantities  of  the 
combined  alimentary  principles  required  to  maintain  nutritive 
equilibrium  are  taken  from  the  works  of  Uffelmann,  Voit, 
Camerer,  and  others  : 


1 84 


DISEASES  OF  THE  STOMACH. 


Age. 


I  week,    . 

1  •' 

2  weeks,  . 
3 

4  "        . 

5  " 

2  months, 

3 
4 

6  " 

1  year, 

2  years, 
3-6 
7 
7-15 


9 

10-15 

Adult  (man,  repose),  .    . 

<<  ((  C( 

"  (man,  light  work), 

"  (woman,  "      "     ), 

"  (man,  hard  work), 

"  (man,  forced  work), 


Weight. 


Per  kilo. 

Total 
Per  kilo. 

Total 

Per  kilo. 

Total 
Per  kilo. 

Total 
Per  kilo. 


Total 

Per  kilo. 

Total 


Per  kilo. 
Total 


Albl'.min. 


Fat. 


Carbohy- 
drates. 


3-7 

2-5 

4-4 
4-8 
5.6 
7-2 
4-5 
9.2 
4-2 

10.3 
4- 
4-1 
3-6 

55- 

28. 

60. 

61. 

75- 

100. 

no. 

90. 

no. 

145- 


43 
10.2 

7-4 

5-6 
22.4 
28.5 

5-2 
36.6 

4.6 
40.7 

4- 

4- 

3- 
25- 

2. 

44- 
47- 
30. 
0.8 
56. 
56. 
40. 
80. 
100. 


4-4 

17-5 
10. 

5-7 
3S.6 
49.2 

5-4 
63.2 

5- 

70.3 

8-5 

S. 

10. 

180. 

10. 

150. 

200. 

250. 

7-5 
400. 
500. 
400. 
500. 
500. 


Mother's 
Milk. 


250  gm. 

550  gm. 
700  gm. 

900  gm. 

1000  gm. 


The  following  table  gives  the  quantity  of  the  alimentary 
principles  in  the  foods  most  frequently  ordered  in  the  treat- 
ment of  diseases  of  the  stomach  : 


Food.  Albumin.  Fat. 

Lean  beef, 20.7  1.7 

Beef-pulp  free  from  fat, 20.  0.5 

Medium  beef, 21.  5.4 

Fat  beef, 16.7  29.3 

Fat  hind  quarter, 20.8  23.3 

Fat  (steer)  tenderloin, iS.S  16.7 

Fat  (heifer)  tenderloin, 19.2  5.8 

Boiled  beef  (medium),' 34.1  7.5 

Roast  beef  (medium), 34.2  8.2 

Fat  veal,  18.9  7.4 

Lean  ve.ll, 19.9  0.8 

Veal  chop, .  20.2  6.4 

Broiled  veal  chop, 29.  12. 

Fat  lamb  (quarter), 9.7  35.8 

Lean  mutton  (quarter), il.i  25.4 

Mutton  chop, 14.3  8.6 

Breast  of  young  chicken, 19.4  2.8 

Lean  chicken, 23.3  3. 1 

Pheasant, 25.3  1.4 

Pigeon 22.1  I. 

Ham, 24.7  36.5 

Scraped  raw  ham  (lean), 23.5  1.5 


DIET. 


185 


Food.  Albumin.  Fat.  Carbohydrates. 

Bouillon, 0.4  0.6 

Expressed  beef  juice, 7.  0.5 

Veal  extract  (bottle), 2.8  ... 

Beef      "  "  1.8  ... 

Oysters, 10.  1.5 

Barley  meal, 12. 5  i. 

Flour,      13.6  I. 

Oatmeal, II.6  5. 

Rice, 7.5  0.6 

Bread, 6.8  1.5 

Dry  toast, 9.5  i. 

Crackers, 7-5  5- 

Potatoes, 1.5  2. 

Mashed  potatoes  (milk),   ....     3.1  0.9 

Cauliflower, 2.5  0.4 

Asparagus,      1.5  0-3 

Ripe  grapes, 0.6  ... 

Prunes, 2.4  0.5 

Sole, II. 9  0.3 

Brook  trout, 19.2  2.1 

Carp, 21.9  I. 

Mackerel, 19.4  8. 

Pike, 18.4  0.5 

Cod, 16.2  0.3 

Spinach,      2.5  0.6 

Apples, 0.4  0.8 

Grapes, 0.6  0.8 

Strawberries, I.  0.9 

Honey, 1.2  ... 

Cane-sugar, 0.3  ... 

Beet-sugar, 2.3  .    .    . 

Macaroni,    .    .         9.  0.3 

Wheaten  grits, 10. 4  0.4 

Graham  bread, 9.  I. 

Albumin.    Carbohydrates.    Alcohol. 

Beer, 0.5  5.2 

Bordeaux, 0.3 

Rhine  wine, 0.5 

Tokay, 15-22 

Champagne, 8.5-II-5 

Cognac,       ... 

Brandy, ... 


3-5 
10-15 
10-15 
16-18 
12. 
60. 
45- 


A  knowledge  of  the  quantity  of  food  required  to  meet  the 
demands  of  nutrition  is  of  value  in  many  respects.  It  is  the 
basis  of  a  diet  selected  with  a  view  to  support,  or  to  reduce, 
or  to  increase  the  weight  and  strength.  It  reveals  by  com- 
parison the  cause  of  emaciation  in  many  cases  of  disease  of 
the  stomach — viz.,  an  insufficient  diet.  It  makes  it  possible 
to  avoid  excessive  eating  and  overtaxing  the  digestive  organs, 
and  the  oft-resulting  myasthenia,  stagnation,  and  fermenta- 
tion. 


1 86  DISEASES  OF  THE  STOMACH. 

There  is  no  doubt  that  a  strong,  well-nourished  body  pos- 
sesses a  greater  resistance  and  healing  power  than  one  which 
is  weak  and  starving  ;  but  in  the  treatment  of  the  diseases  of 
the  stomach  an  insufficient  diet  must  often  be  prescribed. 
Short  abstinence  and  the  consequent  complete  repose  of  the 
stomach  is  an  essential  indication  in  the  treatment  of  acute 
gastritis.  Ulcer  may  also  compel  the  use  of  an  insufficient 
diet.  Even  the  dynamic  affections  may  render  a  more  or 
less  complete  temporary  withholding  of  food  imperative  or 
advisable.  Myasthenia  may  demand  a  reduction  in  the  quan- 
tity of  food  below  what  is  necessary  to  support ;  for.  as  a 
general  rule,  the  larger  the  quantity  the  longer  is  the  sojourn, 
and  it  is  always  imperatively  necessary,  whenever  possible, 
that  the  stomach  should  completely  empty  itself  between 
meals. 

The  result  of  an  insufficient  diet  is  subnutrition,  which 
renders  it  necessary  for  the  body  to  live  in  part  on  itself. 
More  than  twice  as  much  body  albumin  is  dissimilated  in 
proportion  to  the  body  fat  when  the  patient  is  lean  (1:4)  than 
when  the  patient  is  fat  (1:9).  The  total  quantity  of  the 
blood  is  decreased,  and  the  serum  becomes  poorer  in  albumin. 
The  cells  of  the  body  do  not  lose  their  power  of  multi- 
plying. This  innate  and  vital  function  of  the  cells  is  only  in 
abeyance,  and  again  becomes  active  in  proportion  to  the  in- 
creased ingestion  of  food.  This  principle  is  well  illustrated 
by  the  renewal  of  the  body  during  convalescence  from  severe 
acute  diseases.  Subnutrition  produces  no  injury  if  the  latent 
recuperative  powers  of  the  patient  are  not  lessened,  and  the 
diseased  stomach  may  be  favored  without  fear  of  permanent 
injury  by  subnutrition  provided  digestion  and  assimilation 
are  so  improved  thereby  as  to  render  it  easy  to  restore,  at  any 
moment,  the  loss  of  weight  and  strength. 

It  is  often  difficult  to  make  the  choice  between  reducing 
the  body  and  injuring  the  stomach,  for  a  blow  aimed  at  one 
may  strike  both.  The  difficulty  may  often  be  overcome  by  re- 
ducing the  nutritive  demands  to  a  minimum  by  absolute  rest 
in  bed,  and  by  supplementary  rectal  feeding.  But  stomach 
rest  usually  means  the  selection  and  diminution  of  the  quan- 
tity of  the  food  so  as  to  support  the  body  in  repose  and  to 
demand  the  least  possible  functional  activity  of  the  stomach. 
In  some  cases,  on  account  of  pain,  or  loss  of  appetite,  or 
vomiting,  it  is  difficult  to  obtain  the  ingestion  or  retention 
of  enough  food  to  maintain  nutrition.  In  others,  moral 
suasion  and  tonics  will  fail  to  secure  the  eating  of  enough 
food,  or  of  the  right  kind,  to  build  up  the  weight  and  strength. 


DIET.  187 

The  only  valuable  resource  then  left  is  artificial  and  forced 
feeding. 

This  is  a  very  valuable  method  of  alimentation  in  some  of 
the  diseases  of  the  stomach.  In  anorexia  nervosa  forced  ali- 
mentation may  be  employed  with  the  prospect  of  obtaining 
excellent  results.  Whenever,  in  organic  disease,  the  patient 
persistently  eats  too  little  food,  the  additional  quantity  should 
be  introduced  through  the  tube,  if  there  be  no  danger  in  its 
employment  and  if  there  exist  no  reason  why  the  additional 
food  can  not  be  digested  and  absorbed,  as  would  be  the  case 
in  myasthenic  and  in  obstructive  retention.  Pain  is  another 
cause  of  inanition  in  the  diseases  of  the  stomach,  the  patient  by 
gradual  exclusion  adopting  a  starvation  diet.  This  is  com- 
monly the  case  in  hypersthenic  gastritis  and  the  diseases 
which  it  complicates.  In  neurasthenia  gastrica  the  digestive 
discomfort  may  produce  a  dread  of  food.  Artificial  feeding 
will,  under  these  circumstances.be  found  a  valuable  remedy. 
The  use  of  tube  feeding  may  also  be  advisable  in  ulcer,  where, 
on  account  of  pain,  the  fear  of  food  is  great,  or  where  vomiting 
becomes  uncontrollable.  If  the  stomach-tube  be  introduced 
to  the  lower  third  of  the  esophagus,  or  even  just  through  the 
cardia,  the  food  may  be  introduced  through  it  without  danger 
in  ulcer,  and  with  a  good  prospect  of  its  retention. 

It  is  a  curious  fact  that  food  introduced  through  the  tube 
is  often  retained  when,  if  swallowed,  it  is  invariably  rejected 
by  the  stomach.  In  nervous  vomiting  artificial  feeding  is  a 
valuable  remedy,  and  may  be  the  only  means  of  obtaining 
the  digestion  and  absorption  of  enough  food  to  maintain 
nutrition. 

Excellent  preparations  for  the  administration  of  food  by 
the  tube  are  combinations  of  milk,  expressed  meat  juice, 
meat  powder,  raw  eggs,  sugar  of  milk,  and  bouillon.  The 
following  combinations  are  often  well  borne : 

Milk, 500. 

Meat  powder, 30. 

Milk-sugar,      T 20. 

Or— 

Bouillon,       300- 

Meat  juice,       50. 

Or— 

Meat  powder, 30. 

Two  raw  eggs. 

2.  Those  foods  should  be  selected  zvJucJi  can  be  best  digested 
and  utilized  and    are   least  likely   to  ferment  or   decompose. 


1 88  DISEASES  OF  THE   STOMACH. 

Each  individual  lias  his  own  opinion  of  the  digestibility  of 
the  various  foods.  Physicians  themselves  are  as  much  at 
variance  about  the  matter  as  are  the  patients.  Such  a  state  is 
regrettable.  False  impressions  and  narrow  theories,  as  they 
always  do,  have  led  either  to  bigotry  or  to  agnosticism.  The 
one  rejects  all  investigations  as  useless ;  the  other  bends  all 
facts  to  one  theory.  Both  methods  are  equally  disastrous  to 
the  patient. 

The  point  of  view  has  been  wrong.  The  digestibility  of 
food  must  be  defined  and  studied  from  the  point  of  view,  not 
of  hygiene  or  physiology,  but  of  the  physician.  The  value 
of  food  as  a  remedy  is  dependent  upon  its  physiological  action 
and  upon  the  ease  and  certainty  with  which  it  undergoes  trans- 
formation and  absorption.  In  order  to  use  food  rationally  as 
a  remedy  it  must  be  known  in  a  particular  manner. 

The  duration  of  the  sojourn  of  a  food  in  the  stomach  is  no 
full  measure  of  its  digestibility.  The  investigations  of  Gorse, 
Spallanzani,  Beaumont,  Richet,  Busch,  and  Kiihne  only  show 
the  work  of  the  stomach  as  a  motor  organ  in  certain  patho- 
logical conditions.  Gorse  and  Spallanzani  (1785)  made  their 
observations  on  a  ruminating  patient.  Merycism  is  a  neuro- 
muscular affection  of  the  stomach,  and  the  rapidity  with  which 
a  food  is  passed  through  the  pylorus  gives  no  indication  of 
the  ease  with  which  it  undergoes  digestion  in  health. 

Beaumont  (1838)  made  his  observations  on  Alexis  St.  Mar- 
tin, through  a  gastric  fistula  resulting  from  a  gunshot  wound. 
Gastrostomy  had  been  performed  by  Verneuil  on  Richet's 
patient  for  a  benign  stricture  of  the  esophagus.  The  adhe- 
sions of  the  stomach  always  disorder  its  movements,  and  the 
duration  of  the  sojourn  of  a  food  in  a  pathological  organ  is 
no  index  of  the  influence  of  a  given  food,  even  on  the  motor 
function,  in  health.  The  investigations  of  Busch  and  Kiihne 
were  made  through  a  duodenal  fistula.  In  this  case  the 
motor  function  of  the  adjacent  stomach  could  not  be  uninflu- 
enced. Likewise,  the  experiments  upon  gastrostomized  dogs 
show  the  action  of  food  on  the  pathological  stomach  of  a  car- 
nivorous animal,  and  are  not  applicable  to  the  normal  or  the 
diseased  human  stomach.  All  these  investigations  throw 
some  light  on  the  action  of  certain  articles  of  food  on  the 
movements  of  the  stomach  in  certain  pathological  condi- 
tions. The  tables  of  digestibility  constructed  out  of  such 
data  are  almost  valueless  to  the  physician  and  give,  except 
when  the  guess  is  a  happy  one,  altogether  false  results.  The 
end  of  alimentation  in  health  or  in  disease  can  never  be 
attained  so  longf  as  the  influence  of  a  food  on  the  movements 


DIET.  189 

of  an  unhealthy  stomach  is  taken  as  a  full  measure  of  digesti- 
bility. 

Still  more  valueless  are  the  results  obtained  by  artificial 
dicfestion,  which  grive  a  false  idea  even  of  the  resistance  of 
the  food  to  digestive  transformation.  The  stomach  is  not  a 
dry,  motionless  receptacle  with  impermeable  walls. 

The  way  to  scientific  results  was  opened  by  Leube.  The 
digestibility  of  food  in  disease  of  the  stomach  is  displayed  by 
the  manner  in  which  the  food  is  borne  by  the  patient,  by  the 
influence  of  the  diet  on  the  progress  of  the  disease,  and  by 
the  complete  evacuation  of  the  food  before  the  expiration 
of  seven  hours.  Leube,  in  the  determination  of  the  digesti- 
bility of  food  in  disease,  began  with  patients  who  were  able 
to  comfortably  digest  but  little  food  within  the  period  of  seven 
hours.  Beginning  with  these  few  articles  of  most  easily 
digested  food,  a  table  of  decreasing  digestibility  was  made  by 
studying  cases  of  disease  of  less  and  less  severity.  Conse- 
quently, Leube  includes  in  the  conception  of  digestibility  in 
disease  not  only  the  duration  of  the  sojourn  of  a  food  in  the 
stomach,  but  also  the  sensations  which  it  excited  and  the  in- 
fluence which  it  exerted  on  the  progress  of  the  disease.  The 
stomach-tube  was  used  to  determine  whether  the  stomach  was 
empty  at  the  expiration  of  the  arbitrary  seven  hours.  The 
following  progressive  diet  of  Leube  is  extensively  prescribed, 
and  has  proved  very  valuable  : 

I.  Bouillon  ;  Leube-Rosenthal  meat  solution  ;  milk  ;  soft- 
boiled  or  raw  eggs  ;  dry  toast  or  crackers ;  water  or  natural 
indifferent  effervescent  (CO2  )  water. 

IL  Boiled  calf's  brain  ;  boiled  sweetbread  (thymus  of  calf) ; 
boiled  young  chicken  ;  boiled  squab  ;  cereal  soups  ;  tapioca 
cooked  in  milk  ;  boiled  calf's  feet. 

III.  Sirloin  pulp  steak  ;  grilled  sirloin  steak  ;  scraped  raw 
ham  ;  mashed  potatoes,  baked,  with  a  little  milk  and  butter; 
a  little  white  bread  ;  try  coffee  or  tea  with  milk. 

IV.  Roast  beef;  roast  chicken,  venison,  partridge,  and 
veal;  boiled  lean  fish;  macaroni;  bouillon  or  rice  soup; 
spinach  ;  a  little  wine. 

V.  Baked  apple  ;  all  common  foods  ;  finally,  salads,  vege- 
tables, and  stewed  fruits. 

The  method  of  Leube  was  improved  and  employed  by 
Penzoldt,  but  under  better  control  and  under  precautions 
against  error.  The  results  are  comprehensive  and  valuable,  but 
were  obtained  by  the  study  of  digestion  in  health.  The  stom- 
ach-tube was  used  to  determine  the  progress  of  digestion  and 
the  exact  moment  when  the  stomach  is  completely  empty  after 


190 


DISEASES  OF  THE   STOMACH. 


the  eatinf^  of  a  definite  quantity  of  a  particular  food.  The 
table  of  Penzoldt,  which  in  its  chief  articles  is  as  follows,  is  a 
table  of  digestibility  in  health.  The  time  represents  the 
period  within  which  the  food  leaves  the  stomach.  The  quan- 
tity is  given  in  grams: 


One  to  Two  Hoirs. 
100-200  water. 
200  tea        \ 

"    coffee    V    plain. 

"    cocoa  J 

"    beer. 

"    liyht  wine. 
100-200  sterilized  milk. 
200  meat  tea  (pure). 
100  soft-boiled  egg;. 


Two  TO  Three  Hours. 
200  coffee  with  cream. 

"     cocoa  with  milk. 
300-500  water. 

"       "    beer. 

"       "     boiled  milk. 
100  raw  egg  or  omelet. 
250  calfs  brain,  boiled. 

"   sweetbread,  boiled. 

70  raw  oysters. 
200  boiled  carp. 

"       "       pike. 


Two  TO  Three  Hours. 

(Continued.) 
150   cauliflower  (boiled 

or  salad). 
150  asparagus  (boiled). 

"     potatoes  (mashed). 

"    cherry  compote. 

"    raw  cherries. 

20  white  l)read. 

•'  zwieback. 

50  Albert  biscuits. 


Three  to  Four  Hours. 
230   stewed    young 

chicken. 
230  partridge,  broiled. 
240  stewed  pigeon. 
195  roast  " 

250  beef  (raw  or  boiled). 

"    calf's  foot,  boiled. 
160  ham  boiled. 
100  roast  veal. 

"    beefsteak. 


Three  jo  Four  Hours. 

(Cutiiinued.) 
100  beefsteak  pulp. 

'''    roast  beef. 
200  Rhine  salmon. 

70  caviar. 
150  black  bread. 

"     white  bread. 
100  .\lbert  biscuits. 
150  boiled  rice. 

"         "     spinach. 

Four  to  Five  Hours. 
210  roast  pigeon. 
250      "    tillet. 

"    beefsteak,  grilled. 

"    smoked  tongue. 

"    hare. 
240  roast  partridge. 
250     "     goo.se. 
2S0    "     duck. 
150  mashed  lentils. 
200  mashed  garden  peas. 
150  snap  beans. 


Penzoldt  has  constructed  a  progressive  diet  which  is  based 
on  the  digestibility  of  food  by  the  normal  stomach  and  which 
agrees  in  its  main  features  with  that  of  Leube,  which  has 
already  been  given.  Each  diet  consists  of  a  combination  of 
various  foods  and  demands  more  and  more  work  of  the 
stomach. 

First  Diet. — Cup  of  lean  beef  broth  without  salt;  glass  of 
sterilized  milk,  pure  or  with  one-third  lime-water  ;  one  or 
two  boiled  eggs,  or  one  or  two  raw  eggs  stirred  in  hot  meat 
broth;  30  to  40  gm.  of  Leube-Ro.senthal  meat  solution;  6 
crackers  (Albert) ;  li  of  a  glass  of  plain  or  charged  table 
water. 

Second  Diet. — One  hundred  gm.  of  boiled  calf's  brains; 
100  gm.  of  boiled  sweetbread  (thymus  gland  of  calf);  I 
boiled  .squab  ;  i  boiled  chicken  (partridge  size) ;  lOO  gm.  of  raw 
scraped  or  chopped  beef  with  crackers  ;  30  gm.  of  tapioca  in 
milk.  The  meats  should  be  freed  from  fat  and  fibrous  tissue, 
and  had  better  be  stirred  in  meat  broth  before  serving. 

Third  Diet. — One  pigeon  broiled  with  fresh  butter  ;  one 
broiled  chicken  ;  100  gm.  of  rare  roast  beef ;  loogni.  of  scraped 


DIET.  191 

raw  ham  ;  50  gm.  of  zwieback  or  French  roll  ;  50  gm.  of 
mashed  or  mealy  potatoes  ;  50  gm.  of  cauliflower  (bloom) 
cooked  in  salt  water. 

Fourth  Diet — One  hundred  gm.  of  roast  venison  ;  i  roast 
partridge  ;  lOO  gm.  of  rare  roast  beef  (hot  or  cold) ;  lOO  gm.  of 
roast  veal  cutlet ;  lOO  gm.  of  boiled  lean,  fresh  fish  ;  50  gm.  of 
Russian  caviar;  50  gm.  of  thoroughly  cooked  rice  gruel;  50 
gm.  of  boiled  asparagus  (tips) ;  2  scrambled  eggs  with  a  little 
fresh  butter  and  salt  or  omelette  souffle ;  50  gm.  of  sauce  of 
stewed  fruit;  lOO  gm.  of  warm  claret  (Bordeaux). 

A  table  of  digestibility  to  be  of  clinical  value  must  rest  on 
a  broader  basis.  Not  the  influence  of  the  food  on  the 
motor  function  and  on  the  other  functions  of  the  stomach 
in  health,  but  the  ease  and  surety  of  the  useful  and  un- 
conscious transformation  of  food  into  assimilable  nutriment 
by  the  digestive  tube  is  the  clinical  measure  of  digestibility. 
This  clinical  conception  includes  the  following  four  elements  : 

1.  The  food  must  be  easily  soluble  in  the  digestive  juices. 

2.  Its  physiological  action  must  be  such  as  is  most  favor- 
able to  its  digestion  and  absorption,  and  such  as  exerts  a 
remedial  influence  by  favoring  or  exciting  the  diseased  part. 

3.  It  must  not  be  liable  to  undergo  fermentation  or  decom- 
position before  it  reaches  the  point  of  digestion  and  absorp- 
tion. 

4.  Its  digestive  products  must  be  easily  and  quickly  ab- 
sorbed after  their  formation,  or  must  resist  superdigestion  and 
destruction  by  micro-organisms. 

5.  The  digestion  must  be  accomplished  without  pain  or  dis- 
comfort. 

From  a  clinical  point  of  view,  the  digestibility  of  a  food  is 
not  absolute,  but  individual  and  variable.  The  food  and  its 
palatable  properties  are  the  only  fixed  elements  in  the  problem. 
The  stomach  and  the  intestines  are  as  variable  in  power  as  is 
the  general  strength  of  men,  and  are  as  individual  as  the 
human  face.  Often  touched  by  hereditary  taint,  on  both  the 
stomach  and  intestines  are  written  the  biography  of  their 
possessor,  the  record  of  past  diseases,  and  the  salient  points 
in  the  mode  of  life.  Both  become  adapted  to  their  environ- 
ment, which  is  composed,  on  the  one  hand,  of  the  matter  in 
contact  with  the  mucous  membrane,  and,  on  the  other,  of  the 
state  and  characteristics  of  the  organism.  The  food  and  its 
associations,  the  products  of  digestion,  fermentation,  and  de- 
composition, the  flora  of  the  stomach  and  intestines,  are,  for 
no  two  persons,  exactly  the  same.  Secretion  is  variable, 
movement  is   variable,  and  all  of  these  are  individual.     Con- 


192  DISEASES  OF  THE  STOMACH. 

sequently,  individualization  is  a  commanding  principle  of 
dietetics  and  a  modifying  factor  of  digestibility.  A  knowl- 
edge of  food,  of  its  general  digestibility,  of  the  state  and 
needs  of  the  organism  and  of  its  parts,  can  serve  only  as 
guiding  threads.  The  course  is  zigzag,  but  the  variations  in 
health  are  limited,  and  the  variations  in  disease  are  quite 
constant.  An  average  or  sweeping  curve,  however,  can 
be  marked  out  as  a  clinical  guide. 

From  this  point  of  view  the  chief  foods  of  interest  to  the 
physician  in  the  treatment  of  the  diseases  of  the  stomach 
will  be  studied  in  their  physiological  action,  the  degree  of 
resistance  which  they  offer  to  digestive  transformation,  and 
their  liability  to  undergo  destructive  or  injurious  changes; 
and  in  this  study  must  be  included  the  action  on  the  stomach, 
both  in  health  and  in  disease. 

Meats. — The  physiological  action  of  the  meats  is  dependent 
on  their  mechanical  and  chemical  influences,  and  on  the  asso- 
ciations of  the  albumin  with  the  other  alimentary  principles 
and  with  the  products  which  appeal  to  the  palate.  Conse- 
quently, their  physiological  action  is  determined  by  the  fol- 
lowing factors: 

1.  Physical  state. 

2.  The  preparation  for  the  market. 

3.  The  preparation  for  the  table. 

4.  The  associated  products,  of  which  the   chief  one  is  fat. 

5.  The  quantity  eaten. 

Meat  is  the  natural  stimulant  of  gastric  secretion,  an  adap- 
tation, through  use,  of  the  activity  of  a  part  to  the  special 
work  which  it  is  intended  to  perform.  The  means  and  the 
end  are  fitted  to  each  other,  and  special  opportunity  excites 
purposive  activity.  The  chemical  work  of  the  gastric  secre- 
tion is  expended  on  the  albumins,  and  in  the  ordinary  diet 
these  consist  chiefly  and  most  universally  of  the  meats.  Meat 
is  thus  the  chief  natural  excitant  of  gastric  secretion,  and  as 
secretion  is  so  greatly  influenced  by  the  movements  of  the 
stomach,  in  the  course  of  nature  normal  and  suitable  muscu- 
lar action  has  become  associated  with  the  natural  secretion. 
So,  likewise,  with  the  other  functions  of  the  organ.  The 
meats,  then,  excite  the  stomach  to  the  fullest  normal  activity. 
The  process  and  evolution  of  the  digestion  of  meat  represent 
fully  and  truthfully  the  functional  work  of  the  stomach,  pro- 
vided the  meat  is  palatable  to  the  individual  and  does  not 
break  too  rudely  his  diet  habits.  Here,  again,  the  personal 
element  enters  and  destroys  exactness  in  the  detailed  ordering 
of  a  diet.     The  physician  is  the  judge,  and   it  is   his   duty  to 


DIET.  193 

apply  the  general  laws  and  precedent  to  the  individual  case, 
under  the  guidance  of  experience. 

To  represent  the  comparative  evolution  of  the  digestion 
of  meat  and  of  bread  and  milk,  a  piece  of  the  round  of  a 
properly-fattened  two-year-old  steer,  after  hanging,  may  be 
selected,  the  fat  and  fibrous  tissue  cut  away,  and  the  pulp, 
separated  by  a  non-cutting  chopper,  made  into  masses  about 
an  inch  thick  and  two  inches  in  diameter  and  quickly  cooked 
on  a  hot  griddle  so  as  to  leave  the  center  rose-red.  Two  of 
these  may  be  taken  with  a  cup  of  weak  tea. 

Comparatively,  the  gastric  secretion  is  more  intense  and  the 
evolution  of  digestion  is  longer  than  with  either  milk  or  the 
ordinary  roll  test-breakfast.  The  digestion  of  a  glass  of  milk 
is  near  its  end  at  one  and  a  half  hours,  that  of  bread  at  two 
hours,  but  that  of  the  beef  pulp  at  three  and  one-half  hours. 

The  total  hydrochloric  secretion  is  greater  with  the  meat, 
but  it  is  sufficient  and  not  excessive.  At  the  height  of  diges- 
tion there  is  always  a  trace  of  free  HCI,  but  only  a  trace. 
The  HCI  is  utilized,  but  there  is  no  excessive  secretion,  as 
with  the  digestion  of  bread,  and  the  trace  of  free  HCI  con- 
tinues to  the  end. 

The  evolution  of  the  digestion  of  a  beefsteak  or  roast 
beef  is  not  the  same  as  that  of  the  beef  pulp.  The  excitation 
is  more  intense;  less  hydrochloric  acid  is  combined,  even  if 
the  analysis  be  made  on  the  unfiltered  contents ;  more  hydro- 
chloric acid  remains  free  ;  the  duration  of  digestion  is  pro- 
longed ;  and  between  the  third  and  fourth  hours  the  quantity 
of  digestive  products  is  greater.  The  difference  is  due  to  the 
presence  of  fat  and  of  fibrous  tissue,  to  the  larger  particles, 
entailing  more  intense  excitation,  to  diminished  utilization  of 
the  secreted  HCI,  to  accumulation  of  stimulating  digestive 
products,  and  to  delayed  evacuation. 

The  action  of  the  meats  on  secretion  is  dependent  also  on 
the  quantity  which  is  eaten,  for  the  greater  the  quantity  the 
longer  the  sojourn  in  the  stomach.  In  this  respect  the  table 
of  Penzoldt  gives  very  exact  and  valuable  information.  Some 
of  the  meats  are  digested  much  more  slowly  and  others  more 
rapidly  than  the  beef  pulp.  The  greater  the  quantity  of  fat 
and  the  less  minutely  divided  the  meat,  the  longer  is  its  so- 
journ, the  slower  its  digestion,  and  the  more  out  of  propor- 
tion is  the  quantity  of  secretion  to  that  which  is  required  for 
its  transformation.  Young  chicken,  veal,  calf's  brain,  squab, 
and  sweetbread  are  more  digestible  when  boiled,  while  the 
older  and  red  meats  are  better  borne  when  grilled  or  roasted. 
The  meats  are  among  the  best  utilized  foods.     In  health,  only 


194  DISEASES  OF  THE  STOMACH. 

from  three  to  five  per  cent,  of  the  total  quantity  of  albumin 
ingested  is  unabsorbed ;  little  is  destroyed  in  the  digestive 
tube  and  little  is  eliminated  in  the  feces.  But  this  is  true 
only  while  the  functions  of  the  intestines  and  pancreas  remain 
normal.  To  e.xcite  these  functions  physiologically  and  to 
maintain  the  balance  of  nutrition,  other  kinds  of  food  should 
be  combined  with  the  meats.  The  action  on  intestinal  peris- 
talsis is  altogether  insufficient,  but  the  decomposition  products 
may  produce  irritation  and  putrefaction  rf  favored  by  the  ad- 
ministration of  meats  exclusively  and  in  larger  quantity  than 
in  the  normal  diet. 

Meat  furnishes  one  of  the  best  means  of  supplying  the 
nitrogenous  needs  of  the  organism,  but  should  not  be  selected 
when  the  object  is  to  give  the  stomach  physiological  rest. 
Its  gastric  digestion  is  an  example  of  energetic  purposive 
work  without  waste.  In  all  diseases  of  the  stomach  accom- 
panied by  a  diminution  of  the  hydrochloric  acid  secreted, 
the  quantity  of  meats  in  the  diet  should  be  reduced  to  a 
minimum.  The  white  meats  are  preferable  when  it  is  desired 
to  favor  the  stomach,  because  they  contain  less  extractive 
matter,  less  hemoglobin  and  iron,  and,  when  of  the  proper 
kind,  also  less  fat.  The  red  meats  are  to  be  preferred  when- 
ever intestinal  putrefaction  exists  and  whenever  it  is  desired 
to  stimulate  the  stomach  gently  and  to  exercise  it. 

Where  there  is  excessive  hydrochloric  secretion  the  meats 
should  be  given  in  increased  quantity,  in  order  to  combine 
the  acid  and  to  secure  for  the  organism  the  advantages  of  the 
digestive  and  secretory  disorder.  Here  it  seems  to  make 
little  difference  chemically  whether  the  best  of  the  white  or 
the  red  meats  be  given,  so  long  as  both  are  very  finely  divided. 

In  the  dynamic  affections  of  the  stomach  which  are  not 
accompanied  by  a  disorder  of  secretion,  the  meats,  if  properly 
selected,  are  usually  borne.  Some  cases  of  morbid  sensibility 
of  the  stomach  form  an  exception  to  the  rule.  The  meats, 
like  all  other  foods  which  act  energetically  on  the  stomach, 
should  not  be  prescribed  in  the  anemias  associated  with 
vascular  disturbances.  Their  digestion  is  then  often  accom- 
panied by  a  very  rapid  pulse,  and  sometimes  excites  a  bruit  de 
galop,  or  reduplication  of  the  second  sound  of  the  heart,  or 
cardiovascular  dyspnea.  Here  a  milk  diet,  if  there  be  no 
contraindication,  combined  with   rest  in  bed,  is  most  suitable. 

Gastric  putrefaction  is  very  rare,  except  it  occur  as  an  acci- 
dent;  but  intestinal  putrefaction  is  quite  frequent,  and  it  may 
be  necessary  temporarily  to  withhold  all  meats  in  order  to 
control    this    condition.      Gastric    fermentation    is    common 


DIET.  195 

enough,  and  is  often  accompanied  by  intestinal  fermentation. 
An  exclusive  but  temporary  meat  diet  (with,  when  possible, 
a  little  dry  toast  and  lemon-juice)  is  then  by  far  the  best 
treatment.  Some  little  temporary  injury  to  nutrition  may  be 
done  thereby,  and  the  emaciation  should  not  be  allowed  to  go 
too. far;  but  cases  of  this  kind  are  noi  rare  where  no  other 
diet  has  any  permanent  or  curative  effect.  Carcinoma  is  a 
formal  contraindication  to  an  exclusive  meat  diet.  When 
using  meats  in  the  dietetic  treatment  of  diseases  of  the 
stomach,  lean  meat  should  be  selected  and  the  fat  should 
be  carefully  removed.  The  fat  alters  the  digestibility  and  the 
physiological  action  of  the  muscle  pulp,  prolonging  digestion 
and  increasing  excitation. 

The  most  digestible  meats  are  beef,  mutton,  fowl,  some  kinds 
of  game  (grouse,  pheasant,  quail,  venison),  calf's  sweetbread, 
and  calf's  brain.  Goose  and  duck  are  too  fat,  and  stay  in  the 
stomach  about  five  hours.  Pork  should  never  be  permitted, 
but  lean  boiled  ham  is  often  well  borne.  Roast  and  broiled 
chicken  and  squab  are  digested  in  about  three  and  one-half 
hours.  The  young  meats,  and  brain,  and  sweetbread,  should 
not  be  roasted  or  grilled.  Raw  meat  is  no  more  easily 
digested  than  when  it  is  cooked  and  finely  divided. 

The  commercial  preparations  of  meat  are  very  numerous, 
and  their  extensive  manufacture  is  sufficient  evidence  of  their 
great  consumption.  Convenience  and  concentration  are  their 
chief  advantages.  Some  of  them,  when  fresh,  are  valuable 
■both  as  food  and  as  remedies.  The  use  of  most  of  them  in 
the  treatment  of  the  diseases  of  the  stomach  can  be  easily 
dispensed  with  if  a  good  cook  is  at  command,  and  some  of 
them  are  veritable  irritants  and  purgatives. 

The  commercial  albuminous  preparations  which  contain 
large  percentages  of  mineral  and  extractive  matter  excite 
gastric  secretion  and  irritate  the  mucous  membrane  of  the 
alimentary  tract.  Their  transformed  albumins  easily  putrefy 
in  the  bowels,  and  are  no  better  utilized  than  the  albumins 
of  the  ordinary  foods  when  in  solution  or  in  a  state  of  fine 
division.  They  possess  no  greater  nutritive  value  than  is 
represented  by  the  caloric  value  of  the  alimentary  principles 
which  they  contain,  and  they  can  be  administered  only  in  very 
small  quantity  without  disordering  digestion.  The  following 
table  shows  the  nutritive  value  of  some  of  the  prepared  foods 
in  comparison  with  that  of  expressed  beef  juice,  meat  powder, 
eggs,  milk,  and  beef: 


196 


DISEASES  OF  THE  STOMACH. 


Soluble 
Albumin. 


Extractive     Mineral 
Matter.        Matter. 


Caloric 
Value. 


Valentine's  meat  juice,    ....  6.7 

Liebig's  meal  extract,    ....  20.5 

Johnston's  beef  extract,      ...         36.7 

Somatose, 80. 

Nutrose, 90. 

Eucasin, 85. 

Expressed  beef  juice 3. 

Meat  powder, 69.5 

Egg  (white) 

One  egg, 

Milk, 

Beefsteak, 


*         22 

8 

.18 

8 

0 

;      0 

0 

^ 

J 

11.4 

27. 

23- 

84- 

9- 

150. 

6.7 

320. 

0. 

369- 

0. 

348. 

i.S 

12. 

13- 

285. 

53- 

70. 

Somatose,  nutrose,  and  eucasin  are  excellent  preparations, 
but  not  more  than  50  gm.  of  either  can  be  administered  dur- 
ing the  twenty-four  hours  without  disordering  digestion. 
Consequently,  little  more  than  one-half  of  the  nitrogenous 
needs  of  the  body  can  be  supplied  by  these  foods,  and  they 
furnish  only  about  one-fifteenth  of  the  quantity  of  nutriment 
which  is  required  daiU'. 

Bouillon,  meat  broths,  meat  teas,  expressed  meat  juice, 
meat  powder,  etc.,  have  their  special  uses  and  action  on  the 
stomach.  The  indications  for  them  in  the  particular  diseases 
will  be  given  in  Sections  IV  and  V. 

Fish. — On  account  of  the  high  percentage  of  fat,  few  fish 
can  be  employed  in  the  treatment  of  the  diseases  of  the 
stomach  ;  but  when  these  few  can  be  obtained  fresh,  a  very 
delicate,  digestible,  and  valuable  albuminous  food  is  at  our 
command.  The  lean,  fine-meated,  perfectly  fresh  and  boiled 
or  baked  fish  are  the  only  varieties  permissible.  Among 
these  the  following  may  be  named:  sole,  weakfish,  bass, 
trout,  Ger.man  carp,  chicken  halibut,  flounder,  sheepshead, 
pike,  the  lean  parts  of  bluefish  and  of  shad. 

The  action  of  lean  fish  on  the  stomach  is  much  less  ener- 
getic than  that  of  meat.  Secretion  is  not  so  active,  and  when 
fish  is  eaten  alone  is  hardly  suflficient  for  its  digestion.  In  this 
respect  it  more  closely  resembles  the  white  than  the  red 
meats.  Digestive  transformation  is  quite  rapid,  and  the 
stomach  is  empty  in  about  two  hours  after  a  breakfast  of  a 
small  piece  of  sole,  a  little  lemon-juice,  and  a  cup  of  tea. 

The  albumin  of  the  lean  fish  is  well  utilized,  only  about  two 
per  cent,  being  lost.  About  ten  per  cent,  of  the  fat,  how- 
ever, is  recovered  in  the  stools. 

Fish  of  the  kind  recommended  may  be  prescribed  to  give 


DIET.  197 

a  little  variety  to  the  diet,  and  in  larger  quantity  where  meats, 
on  account  of  their  comparatively  high  price,  can  not  be 
secured.  It  is  a  food  which  is  useful  in  favoring  the  stomach, 
but  it  can  not  be  employed  as  a  physiological  remedy  where 
it  is  desirable  to  stimulate  secretion. 

Milk. — Milk  is  one  of  the  most  widely  used  and  important 
foods.  The  only  complete  and  natural  food  in  infancy,  in 
later  life  milk  and  its  products  are  also  largely  consumed. 

Konig  gives  as  a  daily  average  consumption  for  each  indi- 
vidual, ^  of  a  liter  of  milk,  ten  gm.  of  butter,  and  ten  gm.  of 
cheese,  statistics  based  on  the  consumption  in  large  cities. 
In  small  towns  and  in  the  country  the  consumption  is  notably 
greater,  and  may  be  attributed  to  its  cheapness,  nutritive 
value,  palatableness,  and  easy  digestibility  in  health.  Its 
fluid  form  and  its  eliminating  properties  have  won  for  it  a 
very  general  use  in  therapeutics. 

From  a  clinical  point  of  view,  this  complete  fluid  food  is 
not  without  its  imperfections.  The  subjective  symptoms  fol- 
lowing its  use  may  to  some  persons  be  so  disagreeable  and 
peculiar  as  to  reveal  a  so-called  idiosyncrasy,  and  may  be  so 
pronounced  as  to  preclude  its  use.  It  also  forms  a  good 
culture  fluid  for  many  germs,  under  whose  influence  it  rapidly 
undergoes  destructive  changes. 

The  figures  of  Freudenreich  demonstrate  the  high  value  of 
milk  as  a  culture  soil,  and  the  influence  of  the  temperature  on 
germ  growth.  On  arrival  in  the  laboratory,  one  c.c.  con- 
tained 9300  germs : 

At  15°  C.  At  25°  C.  At  35°  C. 

Three  hours  later,  ....           10,000  18,000  39,000 

Six  hours  later,  .....           25,000  172,000  12,000,000 

Twenty-four  hours  later,    .57,000,000  577,000,000  50,000,000 

The  nutritive  value  is  not  only  markedly  diminished  by 
these  germs,  but  the  products  of  germ  activity  are  injurious 
and  modify  its  physiological  action.  The  most  common 
fermentation  products  are  lactic  and  butyric  acids,  and  tyro- 
toxicon  is  formed  by  its  putrefaction.  The  germs  of  fermen- 
tation and  putrefaction  may  be  introduced  into  the  body  with 
it,  or  may  be  found  awaiting  its  arrival  in  the  stomach  or 
intestines.  The  first  imperfection  may  be  partly  remedied  by 
sterilization  when  fresh,  and  this  procedure  is  always  advisable 
in  order  to  avoid  the  introduction  of  pathogenic  bacteria. 
Sterilization  may  be  done  in  the  ordinary  way  with  an  appa- 
ratus like  that  of  Soxhelet.  But  a  better  plan  is  pasteuriza- 
tion.    The  milk   is  kept  at  a  temperature  of  70°  C.  for  five 


198  DISEASES  OF   THE   STOMAC/f. 

minutes,  then  rapidly  cooled  by  placing  it  in  the  ice-box.  It 
is  then  kept  lukewarm  for  about  two  hours,  and  a^ain  heated 
to  70°  C.  The  disadvantages  of  a  high  temperature  are  thus 
avoided,  and  the  resistant  spores  are  germinated  and  killed, 
whereas  by  the  ordinary  method  the  spores  are  usually  not 
killed.  The  milk  should  be  sterilized  or  pasteurized  immedi- 
ately after  the  milking,  while  it  is  perfectly  sweet;  or  in  hot 
weather  it  should  be  kept  cold  until  the  procedure  can  be 
employed. 

For  the  adult,  another  disadvantage  is  its  small  nutritive 
value  in  comparison  with  its  total  mass.  To  suppU' the  num- 
ber of  heat  units  represented  by  the  biological  coefficient  for 
the  adult  of  average  weight,  about  four  liters  are  required 
daily.  In  any  other  condition  than  rest  the  balance  of  nutri- 
tion can  not  be  maintained  at  the  normal  level  on  an  absolute 
milk  diet,  and  its  exclusive  use  by  the  adult  constitutes  a 
starvation-cure. 

The  average  composition  of  milk  is  : 

Cashin  and 
Albumin.  Fat.  Milk-sugar. 

Durham  and  Ayrshire,  3.4  3.5  5.5 

Jersey, 3.3  4.2  5.7 

Guernsey 4.0  5.1  4.4 

Mixed, 3.5  3.7  4.9 

Four  liters, 1400  148.0  196.0 

Repose  ration,     .    .    .  loo.o  50.0  400.0  (carbo- 
hydrates) 

Tiiree  liters,     ....  105.0  lll.o  I47-0 

Theoretically,  four  liters  daily  should  maintain  the  nutri- 
tion of  the  adult;  but  a  large  proportion  of  the  milk-sugar 
may  be  lost  in  disease,  and  about  five  per  cent,  of  the  fat  and 
ten  per  cent,  of  the  casein  are  unabsorbed.  The  milk  is 
markedly  diuretic,  and  increases,  when  given  alone,  the  urea 
elimination  about  one-third  (Chibret).  An  exclusive  milk 
diet,  except  when  the  patient  is  kept  warm  in  bed,  produces  a 
marked  loss  of  strength,  though  the  body  may  lose  little 
weight. 

As  an  ideal  food,  its  combination  of  the  alimentary  princi- 
ples is  defective.  The  carbohydrates  are  deficient  and  the  fat 
is  excessive;  and  until  it  be  proven  that  the  form  of  albumin 
is  of  no  consequence,  its  almost  exclusive  casein  may  be 
considered  a  defect. 

Yet  another  imperfection  is  in  its  digestion  and  utilization. 
Contrary  to  the  general  belief,  a  large  percentage  of  its  ali- 
mentary principles,  when  given  as  an  exclusive  diet,  reappear 
in  the  stools  or  are  lost  bv  fermentation. 


DIET.  199 

The  following  table  of  average  percentages  shows  this  loss 
and  its  increase  with  the  quantity  daily  administered  : 

Casein.  Butter. 

Two  liters,    .    .  5  per  cent,  in  stools.  3  per  cent,  in  stools. 

Three    liters,    .  8  "       '•       "       "  5   "      "        "        " 

Four  liters,    .    .         12  "       "       "       "  6  "       "        "        " 

The  percentage  of  loss  in  disease  may  be  greater,  and  the 
milk-sugar  (none  of  which  is  found  in  the  stools)  may  serve 
entirely  as  food  for  bacteria.  The  caloric  value  of  the  casein 
and  the  butter  which  are  utilized  in  three  liters  is  1450  Cal. 

One  feature  in  its  digestion  is  clinically  of  very  great  im- 
portance— the  products  formed  by  its  coagulation  by  organic 
and  mineral  acids,  and  by  the  labferment,  differ  materially  in 
their  digestibility  and  in  their  physical  and  chemical  proper- 
ties. The  acids  form  a  clot  which  is  the  same  as  clabber. 
The  casein  is  split  by  the  labferment  into  two  products,  one 
of  which  is  casein- albumin  and  is  held  in  solution  by  the 
phosphate  of  lime,  and  the  other  is  precipitated  in  combina- 
tion with  calcium  as  a  base,  and  is  digested  in  the  intestines. 
It  is  practically  important  that  the  curdling  be  produced  by 
the  labferment  and  not  by  an  acid,  as  is  often  the  case  when 
the  stomach  is  diseased. 

The  physiological  action  of  milk  on  the  healthy  stomach  is 
very  slight.  With  a  glass  of  milk  the  height  of  secretion 
occurs  in  about  forty  minutes,  and  at  the  expiration  of  one 
and  one-half  hours  the  stomach  is  empty.  During  its  diges- 
tion there  is  no  free  hydrochloric  acid,  or  the  merest  trace  of 
it.  The  HCl  in  organic  combination  reaches  its  height  sooner 
than  with  the  test-breakfast,  and  the  acidity  due  to  it  is  com- 
monly a  fraction  greater.  As  compared  with  the  digestion 
of  the  test-breakfast  the  digestion  of  milk  is  more  rapid  and 
the  acid  is  more  rapidly  and  completely  utilized.  If  a  large 
quantity  of  milk  be  taken  the  total  acidity  increases,  and 
there  is  often  an  appreciable  quantity  of  lactic  acid,  because 
the  sojourn  in  the  stomach  has  been  longer. 

1.  Gastric  excitation  is  less  than  with  bread. 

2.  The  hydrochloric  acid  is  completely  and  rapidly  com- 
bined. 

3.  In  small  quantity  it  is  evacuated  in  a  short  time ;  and 
there  is  no  sign  of  irritation  left,  such  as  a  tendency  of  secre- 
tion to  continue. 

4.  In  large  quantity  the  secretion  of  hydrochloric  acid  is 
insufficient,  lactic  acid  is  formed  and  inhibits  the  rapid  evacu- 
ation  of  the  chyme.     If  a  notable  quantity  of  lactic  acid  be 


200  DISEASES  OF  THE  STOMACH. 

present,  the  stomach  often  "  splashes  "  about  two  hours  after 
the  beginning  of  digestion. 

The  ph\'siological  action  of  milk  on  the  diseased  stomach 
is  variable.  In  excessive  secretion  with  the  motor  function  in- 
tact it  acts  as  a  sedative,  relieving  irritation  ;  but  in  diminished 
secretion  and  in  motor  insufficiency,  whatever  be  the  state  of 
secretion,  it  undergoes  imperfect  digestion  and  ferments,  pro- 
ducing sometimes  but)'ric  and  sometimes  lactic  acid.  Butyric 
acid  formation  is  frequent  when  the  hydrochloric  acid  is  se- 
creted in  excess.  These  acids  produce  great  irritation  and 
delay  the  evacuation  of  the  contents  of  the  stomach. 

When  milk  is  perfectly  digested  it  exerts  little  action  on 
the  intestines;  the  utilization  is  almost  complete  ;  there  is  no 
excessive  flatulency,  the  urotoxic  coefficient  is  markedly 
diminished,  and  there  is  less  than  the  normal  quantity  of 
indican  found  in  the  urine  after  the  healthy  digestion  of  a 
mixed  meal.  The  lower  half  of  the  bowels  is  given  almost 
complete  rest.  The  action  on  the  motor  function  is  insuffi- 
cient, and  constipation  is  a  very  troublesome  result. 

But  the  intestinal  digestion  of  milk  is  not  always  so  perfect. 
The  lactose  may  ferment ;  the  lactic  acid  formed  is  irritating 
and  constipating,  or  the  butyric  acid  is  even  more  irritat- 
ing and  is  likely  to  produce  catarrh  with  sometimes  diarrhea 
and  an  intense  headache.  The  bowel  may  be  distended 
with  gas,  which  is  chiefly  hydrogen.  Even  when  the  milk 
undergoes  these  changes  and  produces  these  results,  the 
uroto.xic  coefficient  remains  constantly  low.  If  fermenta- 
tion becomes  active  with  an  exclusive  milk  diet,  inanition  is 
rapid.  The  water,  the  lactose,  and  some  of  the  germ  products 
are  actively  diuretic,  and  the  urea  eliminated  is  increased. 
The  loss  of  nutritive  equilibrium  produces  increasing  loss  of 
strength. 

A  very  serious  objection  to  the  employment  of  an  exclusive 
milk  diet  is  the  almost  constant  activity  of  the  stomach  as  a 
consequence  of  its  frequent  administration.  An  exclusive 
milk  diet,  when  digested,  demands  no  very  great  work  of  the 
stomach  at  one  time,  but  it  gives  the  organ  no  rest. 

The  indications  and  contraindications  to  the  use  of  a  milk 
diet  may  now  be  formulated.  The  diet  is  indicated,  not 
when  it  is  possible,  but  when  it  is  better  than  any  other. 

The  milk  diet  is  valuable  in  the  treatment  of  ulcer  of 
the  stomach.  Indeed,  when  in  ulcer  the  motor  function  is 
normal  and  milk  does  not  produce  intestinal  indigestion, 
an  exclusive  milk  diet  is  the  sovereign  remedy,  combining 
the  excessive  hydrochloric  acid  secreted   and   making  little 


DIE  T.  20 1 

demand  on  the  functions  of  the  stomach.  But  it  does  not 
give  the  stomach  functional  rest,  and  if  there  be  gastric  stag- 
nation or  intestinal  fermentation  or  morbid  sensibility  of  the 
duodenum,  it  will  have  to  be  discarded  in  favor  of  another 
diet. 

Milk  is  also  the  best  food  in  the  irritative  stage  of  acute 
gastritis,  provided  it  is  borne  well  by  the  intestines.  But  it 
rarely  agrees  in  acute  gastritis  when  the  contents  are  neutral 
or  very  slightly  acid  or  when  there  is  fermentation. 

A  milk  diet  acts  most  happily  in  adenohypersthenia  gas- 
trica  associated  with  intestinal  putrefaction  and  an  excessive 
quantity  of  indican  in  the  urine.  In  this  special  condition  a 
milk  diet  is  remarkable  in  its  effects,  soothing  the  irritability 
of  the  gastric  glands,  arresting  intestinal  putrefaction,  reduc- 
ing the  congested  liver,  and  relieving  the  auto-intoxication  by 
free  diuresis. 

A  milk  diet  is  contraindicated  in  all  the  diseases  of  the 
stomach  expressed  functionally  by  a  notable  diminution  in 
the  quantity  of  hydrochloric  acid  secreted.  Consequently, 
in  all  cases  of  chronic  asthenic  gastritis,  and  in  many  cases  of 
acute  gastritis,  milk  should  be  prohibited.  It  is  the  worst 
possible  food  in  carcinoma  with  retention.  Milk  should  be 
prohibited  in  all  the  diseases  of  the  stomach  accompanied  by 
retention.  In  some  forms  of  stagnation  it  maybe  proper  and 
valuable  if  it  agrees  well  with  the  intestines.  The  morbid 
glandular  irritability  which  often  accompanies  myasthenic 
stagnation  may  be  relieved  by  a  milk  diet.  If  the  myasthenic 
stagnation  be  relative,  the  stomach  is  often  strong  enough  to 
evacuate  a  glass  of  milk  within  the  normal  period,  but  be- 
comes insufficient  when  a  larger  meal  is  given.  Milk  may  be 
made  the  basis  of  the  liquid  diet  appropriate  in  obstructive 
stagnation.  A  milk  diet  is  often  curative  in  prolonged  diges- 
tion due  to  excessive  secretion,  but  in  all  forms  of  motor 
insufficiency  milk  must  be  forbidden  whenever  it  undergoes 
or  produces  fermentation. 

But  even  when  suited  to  the  stomach,  a  milk  diet  may  be 
contraindicated  by  its  action  on  the  intestines  and  on  nutrition. 
When  the  bowel  is  sensitive  in  its  upper  third,  or  is  myas- 
thenic, or  is  the  theater  of  active  fermentation,  a  milk  diet 
should  not  be  prescribed.  Harm  may  also  be  done  by  pre- 
scribing a  milk  diet  when  the  patient  is  already  weak  and 
emaciated  as  a  result  of  disease  of  the  digestive  tube. 

There  is  no  diet  that  requires  more  careful  watching  and 
selection  than  one  of  milk.  Its  indiscriminate  and  routine 
employment  in  the  diseases  of  the  stomach  gives,  in  the  suit- 


202  DISEASES  OF  THE  STOMACH. 

able  cases,  most  excellent  results,  but  in  the  remaining  cases 
either  does  no  good  or  produces  serious  injury. 

Preparations  of  Milk. — Kcfyr  (so-called  koumiss  of  com- 
merce).— Tiie  most  valuable  preparation  of  milk  in  the  treat- 
ment of  diseases  of  the  stomach  is  kefyr,  which  is  the  product 
of  special  fermentation  of  cow's  milk.  It  is  a  household 
drink  in  the  Russian  Caucasus,  and  is  claimed  to  be  a  gift 
from  Mohammed  to  the  people. 

The  kefyr  ferment  in  the  dry  state  preserves  its  activity 
unimpaired  for  one  or  two  years,  and  is  sold  by  the  Russian 
pharmacists,  often  adulterated,  at  a  high  price  in  the  form  of 
yellowish-white,  dry,  brittle  granules.  Kefyr  contains  essen- 
tially two  germs,  one  of  which,  the  dispora  caucasica  of 
Kern,  converts  milk-sugar  into  lactic  acid  and  partly  into 
an  isomeric  form  which  is  easily  transformed  by  the  other 
yeast-plant  (saccharomyces  cerevisiae)  into  alcohol  and  car- 
bonic acid.  Other  ferments  and  bacilli  have  nothing  to  do 
with  the  formation  of  the  characteristic  product,  but  often 
have  to  be  picked  out  from  the  kefyr  ferment  or  killed  by  a 
weak  solution  of  salicylic  acid.  The  writers  who  have  studied 
the  process  advise  a  thorough  cleansing  of  the  ferment,  after 
each  use,  by  stirring  in  a  one  per  cent,  solution  of  soda  for  a 
few  hours,  picking  out  the  slimy  grains,  and  leaving  the  fer- 
ment for  twenty-four  hours  in  a  i  :  5000  solution  of  salicylic 
acid  m  water.  The  preparation  of  kefyr,  as  described  by 
Biel.  consists  of  two  distinct  parts — the  preparation  of  the  fer- 
ment and  the  transformation  of  the  milk. 

The  dry  ferment  is  soaked  for  about  half  an  hour  in  water 
at  30°  to  35°  C.,and  the  water  is  then  poured  off  and  replaced 
by  fresh  water  at  20°  C,  in  which  the  yeast  is  left  for  twenty- 
four  hours.  The  white  ferment  is  next  washed  on  a  sieve 
with  warm  water,  and  then  added  to  a  liter  of  sweet  sterilized 
milk,  in  which  it  is  left  and  occasionally  shaken  for  twenty- 
four  hours,  when  the  cleansing  is  repeated  and  new  sterilized 
milk  again  used  as  the  culture  fluid.  After  ten  or  twelve  days 
of  this  treatment  the  yeast  rises  to  the  surface  of  the  milk  on 
account  of  the  fermentation  excited,  the  cheesy  odor  is  no 
longer  present,  and  the  milk  shows  a  slight  coagulum  at  the 
end  of  twenty- four  hours.  The  yeast  is  now  ready  for  use  in 
the  preparation  of  the  kefyr. 

A  glassful  of  the  prepared  yeast  is  added  to  a  glass  vessel 
containing  a  quart  of  fresh  sterilized  and  cool  milk,  corked 
with  clean  cotton,  and  set  aside  in  a  light,  airy  room  at  a  tem- 
perature of  about  20°  C. 

After  about  twenty-four   hours,  during  which   the   vessel, 


■DIET.  203 

without  uncovering,  has  been  frequently  shaken,  the  milk 
becomes  creamy  and  has  a  sharp  and  sweet  taste.  The  prep- 
aration is  now  strained  and  bottled.  A  champagne  bottle  is 
filled  about  one-third  full  with  the  prepared  milk,  and  enough 
sweet  sterilized  milk  (preferably  skimmed  milk,  as  the  fat  is 
liable  to  be  decomposed)  is  added  to  almost  fill  the  bottle, 
which  is  then  corked,  fastened,  and  stationed,  top  down,  in 
a  room  at  15°  C.  The  bottles  should  be  shaken  every  two 
or  three  hours,  but  never  uncorked.  The  alcoholic  fermenta- 
tion should  continue  three  or  four  days,  and  when  it  stops 
the  bottles  should  be  kept  on  ice.  For  medicinal  purposes 
it  is  not  advisable  to  use  the  kefyr  until  the  fermentation  has 
spontaneously  stopped  and  a  lasting  foam  forms  on  shaking. 
It  is  more  palatable  than  koumiss  or  matzoon,  should  be 
more  generally  used  than  it  now  is  in  the  United  States,  and 
when  well  prepared  has  the  following  average  composition  : 

Kefvr.    Casein.     Svntonin  and     Butter.      Milk-sugar.     Lactic  Acid.    Alcohol. 
Albumoses. 

100  2.5  I  2-3.5  2  I  I-I.5 

Physiological  Action. — The  physiological  action  of  kefyr  is 
very  different  from  that  of  milk,  and  this  difference  is  due  to 
the  fact  that  it  contains,  in  addition  to  the  usual  ingredients 
of  milk,  a  notable  quantity  of  alcohol,  lactic  acid,  and  the. 
kefyr  bacillus  and  yeast.  In  virtue  of  these  ingredients  the 
excitation  is  more  pronounced  than  that  of  milk,  the  gentle 
action  of  which  both  on  the  secretory  and  motor  functions  of 
the  stomach  is  so  well  known.  As  compared  with  milk,  the 
evolution  of  secretion  is  more  rapid  but  more  prolonged,  and 
the  curve  of  acidity  rises  higher.  The  total  quantity  of  HCl 
secreted  is  greater,  and  a  moderate  quantity  of  free  HCl  is 
present  during  the  second  hour.  The  stomach  seems  to 
empty  itself  more  slowly.  At  the  end  of  two  hours  ordi- 
narily a  small  quantity  of  contents  can  be  withdrawn,  the 
hydrochloric  acidity  of  which  is  still  high.  In  a  word,  the 
secretory  excitation  is  more  intense  and  more  persistent  than 
with  sterilized  milk,  and  its  digestive  transformation  is  much 
more  rapid  and  complete. 

The  physiological  action  on  the  intestines  is  not  marked  in 
health.  Kefyr  is  better  utilized  than  milk,  and  only  a  very 
small  percentage  is  found  in  the  stools.  The  small  percentage 
of  alcohol  promotes  both  gastric  and  intestinal  absorption. 

The  very  small  and  infrequent  stools  reveal  its  inactivity 
on  intestinal  secretion  and  movements.  It  constipates,  but 
rests  the  lower  part  of  the  intestines. 


204  DISEASES  OF  THE  STOMACH. 

Clinically,  the  contraindications  to  the  use  of  kefyr  are 
formal.  In  all  forms  of  irritative  gastric  trouble  it  should  not 
be  prescribed.  It  gives  temporary  relief  in  adenohypersthenia 
gastrica.  as  all  albuminoid  foods  do  ;  but  the  excessive  secre- 
tion of  hydrochloric  acid  is  either  increased  or  not  controlled 
after  long  use.  Alone,  it  is  capable  of  producing  a  catarrh 
in  this  disease,  when  both  the  total  acidity  and  that  due  to 
free  HCl  may  disappear,  or  the  partial  neutralization  b\'  the 
inflammatory  exudate  may  lead  to  an  erroneous  and  too 
favorable  opinion.  In  stagnation  with  fermentation  it  is  injuri- 
ous. In  hyperesthesia  of  the  gastric  mucous  membrane  the 
sensations  of  the  patient  will  soon  call  the  attention  of  the 
physician  to  the  increased  discomfort.  It  is  a  valuable 
remedy  in  all  intestinal  diseases  except  myasthenia. 

In  acute  or  subacute  alcoholic  gastritis,  kefyr  is  most 
valuable.  It  is  especially  useful  after  a  debauch.  In  case 
there  exist  no  forced  contraindication  to  its  use,  on  account 
of  an  associated  condition,  its  employment  in  acute  alcoholic 
gastritis  during  one  to  three  days  gives  very  remarkable  re- 
sults and  is  much  better  in  this  disease  than  ordinary  milk. 

Another  condition  in  which  it  may  be  used  with  benefit  is 
in  subacidity,  whether  associated  or  not  with  a  lesion  of  the 
mucous  membrane.  It  often  acts  very  happily  in  these  cases, 
provided  there  is  neither  myasthenia  nor  morbid  sensibility 
of  the  mucous  membrane.  The  treatment  may  be  begun 
and  continued  for  three  or  four  days  with  kefyr  alone. 

Again,  in  diarrhea,  accompanied  by'  fermentation  and  irri- 
tation, associated  with  organic  or  functional  gastric  subacidity, 
kefyr  may  at  times  be  used  with  advantage.  The  results  are 
more  satisfactory  when  the  diarrhea  is  due  to  putrefaction. 
As  a  food,  it  is  easily  digested  and  rapidly  absorbed  in  the 
stomach  and  upper  part  of  the  small  intestine.  As  a  remedy, 
it  acts  chiefly  by  suddenly  changing  the  culture  soil  of  the 
germs  to  the  action  of  which  the  persistence  of  the  diarrhea  is 
due.  To  change  the  flora  of  the  intestines  it  should  be  used 
as  an  exclusive  diet  for  a  few  days. 

Kefyr  was  introduced  as  a  means  of  inducing  superalimen- 
tation in  the  treatment  of  tuberculosis.  In  the  Russian  es- 
tablishments it  is  given  as  a  supplement  of  a  richer  diet  in  a 
quantity  varying  from  one  to  six  liters  a  day,  as  tolerance  be- 
comes established.  The  quantity  for  the  day  is  divided  into 
three  parts  :  One  portion  is  taken  before  the  meat-breakfast. 
The  second  portion  is  begun  half  an  hour  after  breakfast  and 
finished  an  hour  before  dinner.  The  third  portion  is  begun 
two  hours  after  dinner  and  finished  an  hour  before  supper. 


DIET.  205 

It  is  to  be  taken  slowly  in  sips,  a  short  promenade  preceding 
each  glass.  Given  according  to  this  method,  it  may  be  used 
with  advantage  as  a  supplementary  food  in  affections  of 
the  stomach  when  there  is  no  atony  of  the  muscular  layer. 
During  the  cure  no  other  fluid  should  be  permitted.  The 
results  of  its  use  as  a  surplus  food  in  the  gastric  troubles  of 
phthisis  are  most  excellent. 

Koumiss. — Koumiss  is  a  preparation  of  milk  similar  to  kefyr, 
but,  properly  speaking,  is  made  out  of  mare's  milk.  It  is 
a  drink  of  the  ancient  Scythians,  and  is  very  popular  in 
southern  Russia,  whence  its  use  as  a  remedy  and  a  food 
has  spread  over  the  civilized  world.  It  is  valuable  on  account 
of  its  easy  digestibility.  Koumiss,  outside  of  Russia  and 
Siberia,  is  made  of  cow's  milk  through  a  double  lactic  acid 
and  alcoholic  fermentation.  There  may  be  little  difference 
between  koumiss  and  kefyr,  but  koumiss  is  properly  made  from 
a  combination  of  ferments,  and  not  from  a  pure  culture,  as  is 
kefyr.  An  additional  quantity  of  milk-sugar  is  often  used — 
or  cane-sugar  with  maltose  may  be  used  in  its  preparation  by 
the  yeast  of  beer — and  it  is  ripened  at  a  lower  temperature. 
Consequently,  the  preparation  is  less  constant,  often  too  acid 
or  incompletely  fermented,  and  the  associated  germs  are  very 
variable  and  not  unimportant  in  the  possible  modifications 
of  its  physiological  action.  Kefyr  is  preferable  unless  the 
koumiss  be  prepared  in  a  like  manner  and  given  the  wrong 
name  in  commerce. 

The  third-day  koumiss,  made  of  cow's  milk  with  added 
sugar,  which  is  the  form  used  in  diseases  of  the  stomach,  has 
the  following  average  composition  : 

Syn.tonin 

AND  Milk-    Lactic 

Casein.     Albumoses.     Butter,    sugar.      Acid.      Alcohol. 

Unskimmed  milk,  .    .         2  1.5  3-5  3  i  1-5-3 

Skimmed  milk,  ...         2  1.5  3  i  1-5—3 

The  quantity  of  fat  contained  in  milk  seldom  constitutes 
an  objection  to  its  use  as  a  remedy.  Its  presence  interferes 
little  with  the  chemical  changes  which  milk  undergoes  in  the 
stomach,  but  fat  in  large  quantity,  like  all  sweets,  dimin- 
ishes the  already  slight  action  of  milk  on  the  muscular  layer, 
or,  like  the  fatty  acids,  if  decomposed  produces  an  intense 
congestion  of  the  mucous  membrane. 

The  fat  rises  to  the  top  because  it  is  lighter,  and  not  on 
account  of  any  change  in  the  milk.  But  the  cream  also  con- 
tains casein,  albumin,  sugar,  and  salts,  which  the  fat-globules 
have  carried  along  with  them.     The  upper  layer,  however,  in 


206  DISEASES  OF  THE  STOMACH. 

whicli  the  larger  fat-gtobules  collect,  is  not  so  rich  in  these 
nutritive  ingredients. 

The  method  used  in  skimming  the  milk  and  obtaining  the 
cream  is  important.  The  milk,  after  being  drawn  in  a  clean 
place,  by  clean  hands,  from  clean  udders,  into  clean  vessels,  is 
immediately  sterilized  by  the  spore-killing  process  and  kept 
for  twenty-four,  forty-eight,  or  seventy-two  hours  at  a  tem- 
perature of  io°  to  15°  C.  The  cream  can  then  be  poured  or 
siphoned  off  just  before  drmking.  The  skimmed  milk  is  in 
this  way  perfectly  sweet  and  sterilized.  When  the  machine 
can  be  obtained,  the  milk  before  sterilization  may  be  sepa- 
rated by  the  aid  of  a  centrifugal  apparatus.  The  skimmed 
milk  obtained  in  this  way  is  too  poor  in  fat,  as  much  as  pos- 
sible of  which  should  be  introduced  with  this  already  insuffi- 
cient food.  It  is  well  established  that  the  emulsionized  fat  in 
milk  is  never  contraindicated  by  a  disease  of  the  stomach 
when  milk-sugar  can  be  given.  The  effort  to  e.xclude  the  fat 
of  milk  in  the  treatment  of  the  diseases  of  the  stomach  is  a 
mistake.  Consequently,  no  trial  should  be  made  of  skimmed 
milk  when  sweet  sterilized  milk  is  not  well  borne.  Also 
buttermilk,  clabber,  whe\',  and  peptonized  milk,  and  all  the 
sweet  condensed  preparations,  in  our  experience  are  value- 
less in  the  treatment  of  the  diseases  of  the  stomach. 

The  cream  separated  from  the  milk  in  the  preparation  of 
skimmed  milk  is  a  very  rich,  digestible,  fatty  food,  the  use  of 
which  may  be  advisable  during  the  course  of  the  treatment 
of  some  of  the  diseases  of  the  stomach  when  a  concentrated 
diet  must  be  ordered.     Its  richness  in  nutriment  is  variable. 

Eggs. — The  egg,  a  secretive  and  formative  product  of  the 
reproductive  organs  of  the  female  bird,  is  a  ver\'  valuable  and 
widely-used  aliment  in  both  health  and  disease.  The  compo- 
sition of  the  eggs  of  all  birds  is  nearly  the  same. 

The  Qgg  of  the  hen  varies  in  weight  between  45  and  70 
gm.,  and  is  equal  in  nutritive  value  to  about  40  gm.  of  meat, 
and  contains  about  the  same  quantity  of  albumin  and  fat  as 
150  c  c.  of  milk.  It  is  often  considered  a  complete  food,  but 
it  is  no  more  so  than  fat  meat.  The  physiological  action  is 
modified  by  the  preparation,  and  that  of  the  white  alone  is 
very^  different  from  that  of  the  whole  egg. 

The  hard-boiled  white  of  egg  rapidly  excites  secretion,  and 
the  height  of  digestion  falls  between  thirty  and  forty-five 
minutes,  when  the  quantity  of  combined  and  free  HCl  is 
greater  than  that  of  the  test-breakfast.  In  seventy-five  min- 
utes after  eating  the  white  of  one  egg  the  stomach  is  empty, 
secretion  promptly  ceases,  and  the  products  of  digestion  do  not 


DIET.  207 

accumulate.  If  the  hard-boiled  egg  be  very  finely  divided 
before  it  is  eaten,  secretion  is  less  rapid  and  less  intense,  and 
the  free  HCl  is  less  than  when  the  &^^  is  simply  masticated. 
The  stomach  is  empty  in  one  hour  and  enters  at  once  into 
repose.  The  digestion  of  egg-water  is  like  that  of  the  pul- 
verized white  of  &%z. 

The  digestion  of  the  whole  soft-boiled  or  poached  egg  is 
modified  by  the  increase  of  fat  and  of  salts.  Secretion  is 
slower  in  its  evolution,  digestive  products  are  more  plentiful, 
the  curve  of  free  HCl  is  slower  in  its  descent,  and  the  stom- 
ach is  not  empty  until  near  the  end  of  two  hours. 

The  percentage  of  utilization  in  health  is  very  high.  Only 
about  three  per  cent,  of  the  albumin  and  five  per  cent,  of  the 
fat  escape  absorption.  Both  the  white  and  the  yolk  putrefy 
much  more  readily  than  meat. 

The  whole  q^^  constitutes  a  very  fat  food,  and  very  much 
of  the  yolk  is  unsuitable  in  myasthenia.  The  white  should 
be  lightly  coagulated  or  in  solution  when  rapidity  of  digestion 
is  an  object  and  excessive  excitation  is  to  be  avoided.  The 
white  agrees  well  in  adenohypersthenia,  and  also  in  myas- 
thenia, but  in  both  of  these  functional  states  much  of  the 
yolk  is  likely  to  do  harm.  In  gastric  retention  and  intes- 
tinal putrefaction  eggs  should  be  excluded  from  the  diet.  In 
some  persons  one  egg  may  be  sufficient  to  initiate  intestinal 
putrefaction,  and  to  produce  a  few  colicky  movements  and  an 
abundant  formation  of  hydrosulphuric  acid  gas.  Egg  stirred 
in  bouillon  just  hot  enough  to  coagulate  the  white  is  as  easily 
digested  as  the  soft-boiled  Q-'g^,  but  the  salts  in  the  bouillon 
slightly  increase  the  hydrochloric  acidity.  A  soft-boiled  &^^ 
is  digested  in  less  than  two  hours,  a  raw  or  a  scrambled  ^^^ 
in  two  and  a  half  hours,  but  a  fried  q^^  or  an  omelette 
requires  nearly  three  hours. 

Cereals. — The  cereals  are  very  variable  in  their  digestibility 
and  action  on  the  digestive  tube.  Practically,  only  a  few  of 
them  are  useful  in  the  treatment  of  the  diseases  of  the  stom- 
ach, but  these  few,  on  account  of  the  digestible  starch  which 
they  contain,  possess  a  unique  and  commanding  value.  Of 
these,  the  preparations  of  wheat,  rice,  hominy,  and  oatmeal 
are  the  most  important. 

The  physiological  action  of  common  bread  on  the  healthy 
stomach  is  well  known,  forming  the  only  solid  constituent  of 
the  Ewald-Boas  test-breakfast.  The  action  on  secretion  is 
somewhat  in  excess  of  the  requirements  of  its  digestion. 
At  the  end  of  half  an  hour,  traces  of  free  HCl  may  he 
found   unutilized,    and  at  the   expiration    of    one    hour  this 


208  DISEASES  OF   THE   STOMACH. 

free  liydrochloric  acidity  is  increased  to  a  considerable  quan- 
tity, and  is  represented  by  a  decinormal  acidity  of  lo  to  15, 
which  persists  until  the  stomach  is  empty.  The  evacuation 
of  the  stomach  is  complete  in  about  two  hours,  and  there  is 
no  great  accumulation  of  digestive  products.  The  motor 
function  is  sufficiently  stimulated. 

The  intestinal  digestibility  and  action  are  very  different  from 
those  of  any  of  the  foods  which  have  been  thus  far  considered. 
A  very  large  percentage  of  the  albumin  and  fat  is  unabsorbed. 
A  much  greater  quantity  than  of  the  meats  or  fish  or  milk 
or  eggs  is  used  in  feces  formation,  and  intestinal  peristalsis  is 
more  regular  and  efficient.  This  action  on  the  movements  of 
the  bowels  is  an  advantage,  but  the  loss  of  unabsorbed  nutri- 
ment is  very  great.  From  i  to  20  per  cent,  of  the  albumin 
and  nearly  half  of  the  small  quantity  of  fat  are  recoverable  in 
the  stools.  The  starch  is  utilized  to  within  one  per  cent,  in 
health,  and  though  in  disease  the  quantity  found  in  the  stools 
is  not  much  increased,  the  clinical  guides  often  show  a  large 
loss  by  fermentation. 

In  disease,  the  physiological  action  of  bread  on  the  diges- 
tive tube  is  remarkably  modified  if  the  starch  undergoes  fer- 
mentation. The  lactic,  butyric,  and  other  acids  formed  may 
produce  extreme  irritation.  The  starch  itself,  in  excessive 
secretion,  is  incompletely  digested  by  the  saliva,  and  often 
increases  the  glandular  irritation  and  activity. 

The  bread  used  in  the  treatment  of  the  diseases  of  the 
stomach  should  be  made  of  very  finely-ground  white  flour. 
With  the  whole  wheat  bread  the  utilization  is  much  lower, 
and  the  gastric  excitation  in  health  somewhat  greater  than 
with  white  bread.  About  30  per  cent,  of  the  albumin  of 
the  whole  wheat  bread  is  recoverable  in  the  stools,  and  from 
five  to  ten  per  cent,  of  the  starch  escapes  absorption  and  fer- 
mentation. Clinical  experience  and  the  use  of  the  clinical 
guides  prove  that  the  crust  of  bread  or  dry  toast  browned 
through  and  through  is  well  borne  in  the  diseases  of  the 
stomach. 

The  wheaten  grits  are,  when  thoroughly  cooked,  suitable 
for  the  treatment  of  the  diseases  of  the  stomach.  In  their 
digestion  the  hydrochloric  acid  is  better  combined,  as  a 
rule,  than  with  the  test  breakfast.  They  contain  also  more 
gluten,  which  is  utilized,  when  thus  separated  by  the  cooking 
with  water,  as  well  as  the  albumin  of  meat.  The  starch  is  also 
more  freely  liberated.  Consequently,  a  greater  percentage  of 
nitrogenous  matter  is  absorbed  than  with  bread.  The  wheaten 
grits  ferment  more  readily  than  the  crust  of  roll  and  dry  toast. 


DIET.  209 

Rice  is  another  cereal  which  contains  starch  in  a  digestible 
form,  when  properly  cooked  by  prolonged  steaming.  It  con- 
tains very  little  fat,  and  less  albumin  than  wheat,  but  does  not 
differ  materially  in  its  digestibility  and  physiological  action 
from  wheaten  grits.  Its  composition  constitutes  it  the  best 
of  the  whole-grain  cereals  for  obtaining  the  proper  quantity 
of  starch,  which  is  very  digestible  when  the  rice  is  thoroughly 
cooked  and  passed  through  a  fine  sieve.  Its  starch  is  nearly 
all  utilized,  but  its  albumin  is  less  easily  digestible  than  that 
of  wheat  or  corn  bread.  "  Flaked  rice  "  is  a  very  digestible 
and  palatable  preparation. 

Oatmeal  contains  a  large  quantity  of  fat,  and  more  albumin 
and  less  starch  than  rice.  Its  high  percentage  of  vegetable 
and  badly-utilized  fat  constitutes  a  serious  objection.  It 
remains  longer  in  the  stomach  than  does  rice  or  wheaten 
grits ;  it  produces  greater  excitation  and  is  more  likely  to 
undergo  fermentation. 

Cornmeal  contains  less  fat  than  oatmeal,  and  in  the  form  of 
thoroughly  cooked  "  mush  "  or  "  flaked  hominy  "  is  better 
utilized  than  any  of  the  other  cereals.  More  than  90  per  cent, 
of  both  its  albumin  and  fat  are  absorbed.  It  remains  a  little 
longer  in  the  stomach  than  the  preparations  of  wheat  and 
rice.  Its  action  on  the  stomach  differs  little  from  that 
of  rice,  but  its  intestinal  digestion  and  absorption  are 
better. 

The  cereals  are  not  suitable  for  furnishing  the  body  with 
its  albumin  and  fat.  From  10  to  75  per  cent,  of  the  albumin 
of  the  cereals  is  recoverable  in  the  stools,  but  only  two  to  five 
per  cent,  of  the  albumin  of  meats,  fish,  and  eggs  is  lost.  An 
exception  should  be  made  of  the  gluten  preparations,  which 
are  valuable  when  a  digestible  form  of  albumin  which  resists 
putrefaction  is  required.  Animal  albumin,  except  cheese, 
putrefies  much  more  readily  than  vegetable  albumin.  But 
these  cereals  contain  the  best  form  of  starch. 

In  excessive  secretion  accompanied  by  fermentation  these 
foods  are  imperfectly  digested  and  the  physiological  action  of 
their  fermentation  products  is  injurious.  They  should  also 
be  excluded  in  gastro-intestinal  fermentation.  In  simple 
myasthenia,  and  in  all  diseases  where  the  motor  function  is 
preserved,  or  where  there  is  no  excessive  fermentation,  they 
may  be  properly  prescribed.  They  are  sometimes  not  well 
borne  when  the  stomach  is  morbidly  sensitive.  Intestinal 
putrefaction  is  no  contraindication  to  their  employment ;  and 
they  combine  rapidly  large  quantities  of  HCl,  and  leave  the 
stomach  early  and  easily. 
14 


2IO  DISEASES  OF  THE   STOMACH. 

Potatoes. — Anotlier  food  uliich  is  sometimes  prescribed,  but 
which  is  rarely  useful  in  the  treatment  of  the  diseases  of  the 
stomach,  is  the  Irish  potato.  Only  when  steamed  or  baked 
and  mealy,  or  boiled  and  mashed  and  again  baked,  with  a 
little  milk  and  butter,  should  it  be  permitted,  until  late  in 
convalescence. 

The  potato  excites  a  very  active  gastric  secretion,  the  hydro- 
chloric acid  being  left  free  very  early  in  the  evolution  of  diges- 
tion. The  free  acidity  at  the  end  of  forty-five  minutes  is 
nearly  double  that  of  the  test-breakfast  at  one  hour.  The 
motor  function  is  also  aroused,  and  the  evacuation  of  the 
stomach  is  more  rapid  than  with  the  cereals.  The  starch  is 
badly  utilized  by  the  intestines,  fermentation  is  favored  and 
often  initiated,  and  the  small  quantity  of  nitrogenous  matter 
easily  putrefies,  so  that  the  stools  are  foul,  acid,  and  ferment- 
ing. The  potato  is  valueless  as  a  remedy  in  any  digestive 
trouble,  although  it  is  a  nutritious  food  when  digested.  The 
starch  of  the  potato  (seven  per  cent,  lost)  is  not  so  well  util- 
ized as  that  of  the  preparations  of  wheat  (one  per  cent,  lost), 
rice  (one  to  five  per  cent,  lost),  and  cornmeal  (three  per  cent, 
lest).  One-third  of  the  albumin  of  the  potato,  unless  de- 
stroyed by  putrefaction,  is  recoverable  in  the  stools. 

Fats. — The  fats  are  not  digested  by  the  stomach,  but  they 
exert  a  decided  action  on  this  organ.  The  diseases  of  the 
stomach,  except  gastric  retention,  have  no  influence  on  the 
utilization  of  the  fats,  which  is  the  work  of  the  bile,  pancreatic 
juice,  and  intestines.  In  large  quantities,  fat  irritates  the 
stomach,  delays  evacuation,  and  interferes  with  the  digestion 
and  utilization  of  albumin  and  the  carbohydrates.  The  irri- 
tation, according  to  Leven,  may  be  so  great  as  to  produce 
intense  congestion  of  the  mucous  membrane.  In  small  quan- 
tity, the  best  fats  are  without  notable  action  on  the  healthy 
stomach  when  taken  with  other  foods. 

The  action  on  the  intestines  varies  with  the  kind  and  quan- 
tity of  fat  employed.  By  far  the  best  utilized  fats  are  butter, 
bone-marrow,  cod-liver  oil,  pure  olive  oil,  and  cream.  No 
other  kinds  of  fat  should  be  permitted  in  the  diseases  of  the 
stomach.  The  products  formed  by  germs  out  of  fat  are 
extremely  irritating,  and  may  produce  auto-intoxication  and 
enteritis. 

As  a  physiological  remedy,  fat  has  no  place  in  the  treatment 
of  the  diseases  of  the  stomach.  The  quantity  should  always 
be  moderate,  and  in  excessive  secretion,  in  fermentation,  and 
in  many  cases  of  myasthenia,  it  should  be  reduced  to  a  mini- 
mum and  the  effect  controlled  by  the  clinical  guides. 


DIET.  211 

Sweets. — Like  the  fats,  the  sweets  can  not  often  be  utilized  as 
physiological  remedies.  Their  action  as  such  on  the  stomach 
and  intestines  is  one  of  excitation  of  secretion  and  peristalsis. 
The  action  on  the  stomach  varies  according  to  the  quantity 
and  concentration.  Large  quantities  produce  a  hydragogue 
effect,  the  secretion  being  poor  in  hydrochloric  acid  and  fer- 
ments. In  disease,  their  digestibility  is  greatly  modified,  and 
their  easy  fermentation  constitutes  the  most  serious  objection 
to  their  employment.  Concentrated  solutions  of  sugar  con- 
geal or  may  even  inflame  the  mucosa. 

In  the  diseases  of  the  stomach  with  excessive  secretion,  all 
sweets  must  be  prohibited,  as  they  only  do  harm,  and  are 
eventually  lost  as  food  where  there  is  fermentation. 

If  the  digestive  tube  is  sweet,  the  motor  function  efficient, 
and  the  stomach  is  not  morbidly  sensitive  or  inflamed,  sweets 
should  be  permitted.  Their  action  in  adenasthenia  gastrica 
may  be  beneficial.  Milk-sugar  is  a  better  remedy  than  the 
dextrinized  cereals  of  commerce.  It  is  very  nutritious  (tea- 
spoonful  or  lo  gm.  furnishes  41  Cal.),  excites  secretion  but 
little  when  given  well  diluted  and  in  small  quantity,  and  is  a 
valuable  laxative  food. 

Green  Vegetables. — Green  vegetables,  finely  divided,  tender, 
and  thoroughly  cooked,  may  be  permitted  in  the  diseases  of 
the  stomach  where  there  is  no  excessive  secretion  nor  reten- 
tion. Given  alone,  they  excite  more  gastric  secretion  than  is 
required  for  their  digestion,  and  remain  a  long  time  in  the 
stomach.  Their  large  indigestible  residue  and  their  resistance 
to  fermentation  make  them  valuable  where  constipation  is 
troublesome.  The  best  of  these  are  spinach,  tender  string- 
beans,  carrots,  and  lettuce  as  a  salad.  Asparagus  and  toma- 
toes, on  account  of  their  acids  and  the  small  seeds  of  the 
latter,  may  irritate  a  sensitive  mucous  membrane.  The  nutri- 
tive matter  in  the  green  vegetables  is  badly  utilized. 

Fruits. — Fruits,  on  account  of  their  acid  or  sugar  and  their 
tendency  to  ferment,  should  be  excluded  in  all  diseases  of 
the  stomach  where  there  is  excessive  secretion,  morbid  sensi- 
bility, and  fermentation.  As  a  rule,  baked  apples,  ripe  peaches, 
grapes,  and  prunes  (which  are  among  the  most  suitable)  can  be 
permitted  in  such  diseases  only  when  convalescence  is  well 
advanced. 

The  digestibility  of  food  in  health  is  modified  by  the  dis- 
eases of  the  stomach.  The  digestive  power  of  the  stomach 
in  each  of  its  diseases  will  be  discussed  with  the  different 
diseases.  It  may  here  be  once  more  emphatically  stated 
that  the  digestibility  of  food  in  health  is  not  the  same  as  in 


212  DISEASES  OE  THE  STOMACH. 

disease.     It  is  only  one  guiding  thread  in  the  search  for  a 
proper  diet. 

3.  The  physiological  action  of  the  food  and  of  its  digestive 
products  sJiould  be  such  as  to  reuiedy  or  favor  the  disordered 
functions  and  anatovdcal  lesions.  Food,  in  the  treatment  of 
the  diseases  of  the  stomach,  should  be  used  not  only  as  a 
source  of  nourishment,  but  as  a  remedy  exercising  a  special 
action  on  sensation,  secretion,  peristalsis,  absorption,  and  the 
local  circulation.  The  functional  and  bacteriological  signs 
are  guides  in  the  selection  of  a  digestible  diet  in  the  treat- 
ment of  the  diseases  of  the  stomach  ;  but  the  general  digesti- 
bility of  food  in  health  is  not  so  important  as  its  digestibility 
in  the  particular  diseases.  Fortunately,  the  functional  power 
in  the  well-defined  diseases  of  the  stomach  is  quite  constant, 
and  the  diet  should  conform  to  this  capability. 

The  functions  of  the  stomach  are  germicidal,  digestive,  and 
absorptive.  The  germicidal  activit)'  seems  to  be  dependent 
on  the  acid-secreting  power,  and  whenever  secretion  is  inac- 
tive special  care  should  be  taken  to  have  the  food  and  drinks 
sterile  and  sweet.  No  other  dietetic  indication  is  furnished 
by  this  protective  function.  Very  little  is  known  about  the 
disorders  of  gastric  absorption  apart  from  its  diminution  in 
certain  diseases.  The  acute  diseases  of  the  stomach  are 
manifested  by  phenomena  of  irritation  and  demand  a  diet 
which  gives  protection  and  all  possible  functional  rest.  In 
the  chronic  diseases  of  the  stomach  the  digestive  function 
may  be  asthenic  or  hypersthenic.  Asthenia  may  affect  secre- 
tion or  the  motor  activity  and  power  of  the  stomach.  Hy- 
persthenia  may  affect  sensation,  secretion,  and  motor  activity, 
and  it  is  manifested  by  pain,  nervous  unrest,  excessive  or 
continuous  secretion,  and  by  spasm.  The  various  functions 
may  be  separately  affected  or  combinedly  affected  in  the  same 
manner,  or  one  function  may  be  asthenic  and  another  may 
be  hypersthenic.  Whatever  be  the  character  of  the  abnor- 
mal variations,  the  diet  should  be  appropriate  to  the  disorders 
of  sensation,  of  secretion,  and  of  the  motor  function,  and  to 
the  accompanying  fermentation  and  putrefaction. 

Morbid  sensibility  of  the  stomach  is  either  a  dynamic 
affection  or  a  symptom  of  an  anatomical  disease.  The  hyper- 
esthesia of  organic  disease  is  best  treated  by  a  bland,  non- 
irritating  diet.  All  alcoholic  drinks  should  be  excluded. 
Sour  foods  and  acids  are  also  pernicious,  and  no  condiments 
except  a  small  quantity  of  salt  should  be  permitted.  The 
temperature  of  the  diet  is  also  important,  and  the  food  and 


DIET.  213 

drinks  should  be  neither  very  hot  nor  cold.  The  fats,  if 
perfectly  fresh,  are  well  borne,  but  the  contrary  is  true  of  the 
sweets,  particularly  in  large  quantities.  Meat  broths  and 
coffee  should  be  excluded,  and  milk  often  disagrees.  The 
meats  should  be  finely  divided  and  the  young  white  meats 
rich  in  gelatin  are  to  be  preferred.  To  these  should  be 
added  the  finely-ground  and  thoroughly-cooked  cereals  and 
some  of  the  green  vegetables. 

There  is  no  fixed  rule  for  the  selection  of  a  diet  in  mor- 
bid sensibility  of  the  stomach  (hyperesthesia  and  neuras- 
thenia) as  a  dynamic  affection.  Here  we  have  to  deal  with  a 
neurosis  extremely  capricious  in  its  likes  and  dislikes.  Con- 
trary to  what  seems  reasonable,  a  soothing,  indifferent  diet 
often  disagrees.  This  is  particularly  true  of  a  milk-cure. 
Nothing  but  a  trial  can  here  guide  us,  and  it  is  a  good  plan 
to  begin  with  a  non-irritating  diet,  and  if  this  does  not  im- 
prove the  symptoms,  to  substitute  therefor,  without  hesitation, 
a  diet  physiologically  more  active  and  stimulating.  Exclu- 
sive diets  are  rarely  well  borne  in  the  nervous  affections  of 
the  stomach,  and  an  insufficiency  of  food  is  a  grave  error. 

In  excessive  secretion,  either  of  an  organic  or  of  a  functional 
nature,  the  diet  should  be  non-irritating,  easily  evacuated, 
and  should  possess  a  high  acid-combining  power.  In  adeno- 
hypersthenia  gastrica  all  condiments  and  mechanically  stimu- 
lating foods  should  be  excluded.  Adenohypersthenia  gastrica 
may  be  converted  by  useless  irritation  into  a  gastritis.  If  the 
patient  be  anemic,  exciting  food  is  often  sufficient  to  disturb 
the  rhythm  of  the  heart's  action  or  to  cause  an  attack  of 
dyspnea;  or,  if  weak,  the  overexcitation  may  produce  tachy- 
cardia and  induce  an  extreme  state  of  depression.  Under  the 
circumstances,  only  harm  can  result  from  an  excitant  diet. 
On  the  contrary,  the  food  should  be  non-irritating  and  as  indif- 
ferent in  its  physiological  action  as  it  is  possible  to  make  it  by 
minute  division,  solution,  or  suspension,  by  the  removal  of 
indigestible  particle's,  and  by  the  omission  of  condiments. 
The  action  of  the  food  on  the  stomach  should  be  reduced 
to  a  minimum  in  order  to  meet  the  physiological  indica- 
tion— which  is  sedative.  The  same  rule  applies  to  hyper- 
sthenic gastritis  and  to  ulcer.  In  excessive  secretion,  of 
both  organic  and  functional  nature,  the  starches  should  be 
reduced  to  a  minimum,  and  in  severe  cases  be  excluded,  for 
the  digestion  of  no  other  class  of  food  leaves  so  much  hydro- 
chloric acid  free.  But  functional  and  organic  excessive  secre- 
tion should  not  be  treated  in  the  same  manner.  In  adeno- 
hypersthenia gastrica  three  moderately  large  meals  should 


214  DISEASES  OF  TJIE  STOMACH. 

be  given  daily,  for  a  large  proteid  meal  will  leave  less  hydro- 
chloric acid  free  and  will  produce  less  chemical  irritation. 
Ulcer  and  hypersthenic  gastritis,  on  the  other  hand,  are 
properly  treated  when  four  or  five  small  meals  composed  of 
bland,  finely-divided  food  are  ordered  daily,  for  it  is  abso- 
lutely necessary  to  reduce  mechanical  as  well  as  chemical 
irritation  to  a  minimum.  A  milk-cure  combined  with  alkalies 
may  agree  well,  combining  the  acid  rapidly  and,  without 
having  produced  irritation,  leaving  the  stomach  after  a  short 
sojourn  ;  but  milk,  on  account  of  the  necessity  of  giving  it 
at.  short  intervals,  allows  the  stomach  little  repose,  and  is 
often  badly  borne  by  the  intestines.  Consequently,  a  diet 
composed  of  a  large  quantity  of  finely-divided,  lean,  red 
meats,  eggs,  and  a  minimum  of  non-irritating  cereals  and  fats 
may  be  more  suitable.  The  sugars  increase  the  quantity  but 
not  the  acidity  of  the  gastric  juice.  In  small  quantit\-  and 
well  diluted  they  should  be  permitted  in  organic  and  functional 
adenohypersthenia,  pro\'ided  the  increase  of  secretion  does 
not  injuriously  prolong  digestion.  Naturally,  all  irritants  and 
stimulants  should  be  excluded,  and  the  diet  made  sufficient  in 
quantity  to  support  nutrition,  aided,  if  need  be,  by  absolute 
rest  and  rectal  feeding.  The  two  commanding  indications  are 
the  control  and  utilization  of  the  secretion  and  the  protection 
of  the  sensitive  mucous  membrane  against  irritation.  The 
object  is  not  necessarily  the  diminution  of  the  digestive  work 
required  of  the  stomach,  but  the  regulation  of  the  diet  so  that 
the  stomach  may  painlessly  perform  such  work  as  it  is  fitted 
to  do. 

In  cases  of  simple  subacidity,  the  greater  part  of  albuminous 
digestion  must  be  done  by  the  intestines.  The  conditions  are 
most  favorable  for  the  digestion  of  the  starches.  The  diges- 
tion of  the  fats  is  but  little  interfered  with.  Consequently, 
the  fats  need  not  be  diminished,  and  the  decrease  of  the 
albumins  should  be  made  up  for  by  a  larger  quantity  of 
starches.  The  diet  may  be  composed  of  meats,  fish,  cereals, 
vegetables,  fruit,  and  digestible  fats.  No  class  of  food  need 
be  excluded.  Evidently,  with  the  exception  of  the  starches, 
nearly  all  the  work  of  digestion  is  thrown  on  the  intes- 
tines, and  this  necessitates  very  fine  division  and  thorough 
cooking  of  the  food.  The  diet  should  be  digestible  by  the 
intestines,  not  prone  to  putrefaction  like  eggs,  and  should 
be  so  regulated  in  quantity  and  bulk  as  to  preserve  the 
motor  function  of  the  stomach.  Milk  is  not  well  borne. 
The  fats  (butter,  cream)  should  not  be  given  in  such  large 
quantity    as    to    produce    diarrhea.      Gastric    stimulation,   in 


DIET.  215 

keeping  with  the  cause  of  the  subacidity,  is  advantageous,  and 
consequently  coffee,  condiments,  sweets,  and  alcoholic  drinks 
in  moderation  may  be  beneficial. 

The  diet  in  the  motor  disorders  is  extremely  important, 
and  in  this  respect  resembles  the  motor  function  itself. 
The  chemical  and  absorptive  work  of  the  stomach  can  be 
performed  by  the  intestines,  and  the  compensation  can  be 
so  complete  as  to  maintain  the  organism  in  perfect  health. 
The  stomach  must,  however,  do  its  own  motor  work,  and  the 
disorders  of  this  function  demonstrate  in  a  striking  manner 
the  great  harm  which  a  diseased  stomach  can  do. 

In  morbid  muscular  irritability  of  the  stomach  a  bland  diet 
is  usually  indicated,  be  the  trouble  vomiting  or  the  too  rapid 
evacuation  of  its  contents  into  the  intestines.  But  this  is  by 
no  means  always  true,  and  a  slightly  stimulating  diet  may  be 
best  tolerated. 

Myasthenia  demands  a  very  special  diet — nutritious  in 
small  bulk,  resisting  fermentation,  non-irritating,  finely 
divided,  soluble,"  sufficient  in  quantity,  and  exerting  the 
proper  physiological  action.  The  quantity  of  water  taken 
during  the  meal  and  during  the  period  of  gastric  digestion 
should  not  exceed  one  glassful,  for  myasthenia  is  a  "  dyspepsia 
of  liquids." 

In  myasthenia  gastrica,  if  the  patient  is  young  and  of 
strong  constitution,  and  there  is  no  contraindication,  the 
excitant  diet  should  be  employed  to  awaken  the  muscular 
layer  and  to  contract  reflexly  the  abdominal  muscles  and 
increase  abdominal  tension.  When  the  myasthenia  is  associ- 
ated with  excessive  hydrochloric  acidity,  no  starches  should 
be  permitted ;  and  "  peptones  "  and  albumoses  will  be  useful 
when  hydrochloric  acid  secretion  is  diminished.  If,  on  the 
other  hand,  the  muscle  is  so  exhausted  as  to  be  both  weak 
and  irritable,  and  if  the  muscular  relaxation  is  due  to  inflam- 
mation of  the  mucous  membrane,  ex.citation  would  only 
cause  tonic  contraction  or  be  ineffectual.  Excitation  would 
act  on  the  stomach  as  does  digitalis  on  a  heart  too  weak  to 
support  it.  Consequently,  a  bland  diet  is  indicated  in  the 
treatment  of  the  irritable  and  myasthenic  stomach.  It  enables 
the  nervous  and  neurasthenic  to  live  without  discomfort  and 
without  disordering  reflexes.  It  relieves  spasm  and  the  stasis 
of  contracture.  The  stomach  churns  and  evacuates  its  con- 
tents, the  bowels  become  regular,  and  the  colon  resumes  its 
normal  caliber.  These  effects  are  not  theoretical,  but  can 
be  demonstrated  by  clinical  observation  and  abdominal  palpa- 
tion. 


2l6  DISEASES  OF  THE   STOMACH. 

Tlie  disorders  of  absorption  affect  chiefly  the  utilization  of 
alcohol  and  the  absorbable  sweets,  which,  when  this  function 
is  in  abeyance,  remain  too  long  in  the  stomach  and  produce 
irritation  and  undergo  fermentation.  Alcohol,  however, 
stimulates  this  function  in  a  state  of  health.  Very  little  is 
known  of  the  disorders  of  gastric  absorption  apart  from  its 
diminution  in  certain  diseases,  and,  fortunately,  the  intestines 
are  capable  of  doing  all  this  work. 

Gastric  fermentation  is  a  very  common  condition,  and  may 
require  a  very  special  diet  or  very  rapid  changes  of  exclusive 
diets.  When  this  condition  exists  as  a  result  of  disease  of  the 
stomach  and  not  of  an  improper  diet  alone,  the  treatment 
should  be  begun  after  very  thorough  lavage.  Meats,  gelatin, 
and  dextrinized  bread  should  form  the  basis  of  the  diet. 
Green  vegetables,  fats,  starchy  foods,  sweets,  and  fruits  may 
be  progressively  added  as  the  disease  of  which  the  fermenta- 
tion is  the  result  is  improved  by  proper  medication.  Gastric 
putrefaction  is  very  rare.  It  necessitates  the  careful  selec- 
tion, and  sometimes  the  exclusion,  of  albuminous  food.  Fer- 
mentation and  putrefaction  are  produced  by  certain  germs 
in  suitable  soils.  The  dietetic  treatment  consists  in  making 
the  contents  of  the  stomach  a  bad  medium  for  the  growth  of 
the  particular  germs  which  are  found.  It  is  a  good  rule  of 
practice  temporarily  to  exclude  the  food  on  which  the  germs 
are  living.  In  rebellious  ca.ses  we  strongly  recommend 
stomach  washing  and  exclusive  rectal  feeding  for  a  few  days. 

Gastric  digestibility  is  the  correlate  of  the  digestive  power 
of  a  particular  stomach.  The  impairment  of  one  or  more  of 
the  functions  in  a  particular  manner  affords  so  many  guiding 
threads  to  the  selection  of  a  proper  diet.  In  the  dynamic 
affections  it  may  be  that  the  diet  must  be  so  regulated  as  to 
favor  the  stomach  in  every  possible  way,  gentle  or  negative 
in  its  influence,  or  it  may  be  that  one  or  more  of  its  functions 
need  excitation.  The  indications  for  the  use  of  diet  as  a 
remedy  capable  of  soothing  or  exciting,  are  furnished  by  the 
subjective  and  functional  signs.  The  stomach  requires  appro- 
priate exercise  and  rest  in  order  to  regain  lost  power.  Always 
to  prescribe  a  favoring  diet  indifferent  in  its  physiological 
action  is  a  very  serious  mistake. 

Not  the  dynamic  affections  only  necessitate  the  selection  of 
the  diet  with  a  view  to  its  physiological  action  ;  the  anatomi- 
cal diseases  of  the  stomach  also  demand  either  stimulation 
or  rest.  Chronic  asthenic  gastritis  furnishes  a  good  illustra- 
tion of  the  value  of  an  exciting  diet,  provided  glandular 
deizeneration  is   not  so  far  advanced  as  to  render  stimulation 


DIET.  217 

useless.  On  the  other  hand,  acute  gastritis  imperatively 
demands  temporary  functional  repose  and  the  use  of  the 
blandest,  most  non-irritating  foods.  Ulcer  and  carcinoma 
should  receive  the  most  careful  protection.  In  Sections  IV 
and  V  the  value  and  applications  of  the  rule  will  be  fully 
illustrated.  The  physiological  action  of  the  food  and  of  its 
digestive  products  should  be  well  considered  in  the  selection 
of  a  diet,  in  order  to  avoid  doing  injury  and  to  secure  its 
full  remedial  influence. 

The  use  of  food  as  a  remedy  often  consists  in  the  ordering 
of  a  diet  which  exercises  or  even  excites  the  functions  of  the 
stomach,  or  which  excites  one  of  the  functions  of  the  stomach 
and  favors  another.  But  not  rarely  gastric  intolerance,  or  a 
gastric  lesion,  or  gastric  weakness  makes  it  necessary  to 
favor  the  stomach  or  to  give  it  absolute  functional  rest. 

The  stomach  may  be  favored  by  diminishing  the  nutritive 
needs  of  the  organism,  by  throwing  the  burden  of  digestion 
on  the  intestines,  and  by  rectal  feeding. 

By  absolute  rest  in  bed  the  nutritive  needs  of  the  organism 
may  be  diminished  by  about  one-fifth,  and  the  work  required 
of  the  digestive  organs  is  made  just  so  much  less.  The 
diminution  of  the  required  digestive  work  may  be  necessitated 
by  the  inability  of  the  digestive  organs  to  utilize  enough 
food  to  support  nutrition,  or  by  the  desirability  of  protect- 
ing the  stomach  when  it  is  the  seat  of  a  severe  lesion,  or  by 
weak  digestion,  combined  with  great  emaciation  and  debility. 

The  healthy  intestines  are  capable  of  digesting  enough 
food  to  maintain  nutrition,  and  the  stomach  may,  conse- 
quently, be  favored  by  selecting  an  intestinal  diet.  The  food 
should  be  very  finely  divided,  liquid,  concentrated,  and  bland, 
and  it  should  be  administered  every  two  to  four  hours  in 
small  quantity.  Milk,  when  it  agrees,  serves  as  an  excellent 
basis  for  the  diet.  But  by  proper  preparation  many  other 
kinds  of  food  can  be  used.  Expressed  meat  juice,  meat  pow- 
der, calf's  foot  jelly,  meat  jelly,  cereals  very  finely  ground 
and  thoroughly  cooked,  are  a  few  examples.  Butter  may 
be  given  with  the  cereals,  or  cream,  and  "vigor  chocolate" 
and  almond  milk  may  furnish  the  requisite  quantity  of  fat. 
The  almond  milk  is  prepared  by  making  an  emulsion  of  20 
almonds  in  a  pint  of  hot  water,  and  in  proportion  of  one  to 
two  of  milk  is  a  palatable  and  nutritive  liquid  food.  The 
prepared  cereals  and  the  albumoses  of  commerce  are  some- 
times valuable.  In  this  connection  somatose  and  panopep- 
tone  merit  special  mention.  But  when  peptones  are  prescribed, 
the  total   quantity  of  nitrogenous   food   for  the   twenty-four 


2l8  DISEASES  OF  THE  STOMACH. 

hours  must  be  reduced  to  a  niiniuuini  in  order  to  avoid  pro- 
duciii<;  diarrhea.  Some  of  the  peptones  of  commerce  might 
be  appropriately  called  purgative  poisons. 

Rectal  feeding  may  be  employed  to  favor  and  protect  the 
stomach.  Whenever  it  is  not  possible  to  nourish  the  body 
by  the  mouth,  or  whenever  food  administered  by  the  mouth 
is  liable  to  produce  injury  or  to  interfere  with  the  cure  of  a 
disease  of  the  stomach,  complementar\'  or  exclusive  rectal 
feeding  should  be  tried. 

The  large  bowel  does  very  little  digestive  work,  but  it  pos- 
sesses the  power  of  converting  small  quantities  of  starch  and 
cane-sugar  into  grape-sugar.  However,  it  absorbs  water, 
sugar,  dissolved  albumin,  albumoses,  and  emulsified  fat.  The 
absorption  is  not  very  rapid  nor  very  great,  and  it  is  rarely 
possible  to  nourish  a  patient  in  even  absolute  repose  for  more 
than  a  few  weeks  by  exclusive  rectal  feeding.  Exceptionally, 
a  patient  with  healthy  digestive  organs,  and  with  a  disease 
which  kills  only  by  starvation  (as  cicatricial  obstruction  of  the 
esophagus),  may  be  kept  alive  for  about  one  year.  In  such 
cases  it  is  prolaable  that  the  enema  is  carried  by  antiperis- 
talsis  into  the  small  bowel  and  there  digested  and  absorbed. 

Indeed,  the  investigations  of  Griitzner  make  it  probable 
that  a  part  of  a  nutrient  enema  is  absorbed  by  the  small  intes- 
tine. This  antiperistalsis  is  favored  by  a  weak  salt  solution 
(less  than  one  per  cent.),  and  explains  satisfactorily  the 
increased  absorption  and  utilization  of  an  enema  which 
contains  a  pinch  of  salt. 

Not  enough  nourishment  can  be  introduced  by  the  rectum 
to  supply  fully  all  the  demands  of  nutrition  ;  consequently, 
the  body  can  be  nourished  b)'  rectal  feeding  only  imperfectly, 
and,  usually,  only  for  a  short  time.  Enough  water  and  salts 
can  be  absorbed  by  the  colon,  but  the  quantity  of  organic 
nutriment  is  altogether  insufficient,  except  in  very  excep- 
tional cases.  Emulsionized  fats,  dissolved  albumins,  and  their 
digestive  products,  alcohol,  starch,  and  the  absorbable  sugars, 
may  all  find  their  way  from  the  large  bowel  into  the  circula- 
tion, and  be  utilized  in  nutrition.  The  dissolved  raw  albumin, 
to  which  a  little  common  salt  is  added,  is  as  readily  absorbed 
as  albumoses  and  commercial  peptones.  Digested  enemata 
possess  no  greater  nutritive  value  than  when  undigested,  and 
are  prone  to  decomposition.  They  are  not  well  tolerated, 
and  often  make  the  patients  extremely  restless  and  mentally 
and  morally  depressed.  But  however  the  nutrient  enema  be 
constituted,  rectal  feeding  is  likely  to  produce  intolerance, 
and  when  too    frequently  repeated,    and    composed  of  pan- 


DIET.  219 

creatized  milk,  may  excite  an  acute  colitis.  Some  patients 
resist  this  method  of  feeding,  and  are  often  unable  to  retain 
the  enema.  For  these  reasons  rectal  feeding  is  not  popular, 
and  is  usually  restricted  in  practice  to  cases  of  necessity. 
The  method  is  employed  much  less  frequently  than  it 
should  be. 

The  valuable  enema  of  Leube  is  prepared  by  mixing 
thoroughly — 

150  gm.  of  beef  pulp  (no  fat). 
50  gm.  of  pulp  of  the  fresh  pancreas  of  the  cow  (no  fat). 
100  gm.  of  lukewarm  water. 

This  mixture  is  warmed  and  injected  slowly  two  or  three 
times  daily  into  the  large  bowel  one  hour  after  employing  a 
cleansing  enema  of  250  gm.  of  lukewarm  water.  It  does  not 
irritate,  the  digestion  taking  place  in  the  bowels.  But  the 
fresh  pancreas  is  not  easy  to  get,  and  the  nourishment  thus 
afforded  is  too  exclusively  albuminous.  For  50  gm.  of  the 
beef  pulp  should  be  substituted  the  yellow  of  one  ^%%,  one 
tablespoonful  of  dextrinized  (heat)  flour,  and  one  gm.  of 
common  table-salt.  These  should  be  stirred  thoroughly  into 
the  lukewarm  water. 

The  following  preparation  of  Boas  is  well  tolerated  and  is 
usually  absorbed  : 

Milk, 250  gm. 

Yolk  of  two  eggs, 

Salt, 2  gm. 

Claret, Tablespoonful. 

Prepared  cereal  food, Tablespoonful. 

Use  one  to  three  in  twenty-four  hours. 

The  preparation  recommended  by  Ewald  is  also  excellent. 
Two  or  three  eggs  are  beaten  up  with  a  tablespoonful  of 
cold  water.  About  a  tablespoonful  of  a  prepared  cereal 
(dextrinized)  is  boiled  with  one-half  of  a  glass  of  a  20  per 
cent,  solution  of  grape-sugar,  and  a  wineglassful  of  claret  is 
added.  Let  it  stand  until  nearly  lukewarm  and  slowly  stir  in 
the  beaten  eggs.  Add  one  gm.  of  salt.  Use  two  or  three 
enemata  a  day. 

These  three  excellent  preparations  may  be  employed  in 
turn.  If  the  contents  of  the  large  bowel  become  acid,  both 
the  milk  and  the  sugar  should  be  omitted,  and  as  a  substitute 
therefor  beef  tea  may  be  used. 

Practically,  the  greatest  obstacle  to  rectal  feeding  is  the  re- 
bellion of  the  bowel  against  the  procedure.  The  rectal  in- 
tolerance, by  proper  care  and   co-operation,  may   usually  be 


220  DISEASES  OF  THE  STOMACH. 

avoided.  The  enema  should  be  warm,  of  the  consistency  of 
a  thick  soup,  non-initating,  not  larger  than  250  gm.,  and 
given  after  careful  cleansing  of  the  bowel.  One  hour  before 
the  administration  of  the  enema  an  injection  of  not  more 
than  300  gm.  of  lukewarm  water  should  be  used;  or,  if  the 
colon  is  already  empty,  the  rectum  should  be  simply  washed 
out  by  the  funnel-siplionage  method.  The  nutrient  enema 
is  slowly  introduced  under  low  pressure,  the  tube  is  removed, 
and  a  soft  towel  is  held  for  a  short  time  gently  but  firmly 
pressed  against  the  anus,  while  the  patient  remains  quiet  on 
the  left  side.  A  soft  tube  with  a  rounded  end-opening  should 
be  used  and  introduced  high  up,  or  only  above  the  sphincter 
if  the  effort  to  introduce  the  tube  above  the  sigmoid  flexure 
produces  pain,  resistance,  and  irritation.  The  enema  intro- 
duced properly  into  the  rectum  will  soon  be  carried  by 
antiperistalsis,  excited  by  the  salt,  high  into  the  colon. 
Where  the  rectum  is  very  irritable,  a  few  drops  of  laudanum 
should  be  added  to  the  enema.  A  nutrient  enema  should 
never  be  given  oftener  than  three  times  daily. 

In  extreme  conditions,  a  small  quantity  of  nourishment 
may  be  given  hypodermically.  A  few  ounces  of  sterilized  oil 
may  be  introduced  in  this  way  during  the  twenty-four  hours, 
and,  combined  with  whisky  hypodermically,  may  aid  rectal 
feeding  in  carrying  the  patient  safely  over  a  period  of  danger. 

Rectal  feeding  may  be  employed  to  maintain  nutrition  and 
to  give  the  stomach  rest  or  protection.  In  cardiac  and  pyloric 
obstruction  or  stenosis  it  may  be  impossible  completely  to 
nourish  the  body  by  the  mouth.  Too  little  food  reaches  the 
intestines,  and  it  may  not  be  advisable  to  resort  to  surgery  for 
relief.  Whether  the  obstruction  be  malignant  or  benign  in 
nature,  life  can  be  prolonged  by  the  employment  of  nutrient 
encmata. 

Rectal  feeding  is  very  valuable  in  the  treatment  of  myas- 
thenic retention.  In  this  condition  the  body  suffers  both 
from  lack  of  food  and  of  water,  and  the  slow  starvation  can  be 
arrested  by  nutrient  enemata,  which  compensate  the  gastric 
insufficiency.  Rectal  feeding  is  not  only  valuable  on  ac- 
count of  the  support  which  it  gives  to  nutrition,  but  also  on 
account  of  the  diminution  of  the  functional  work  of  the 
stomach.  The  favoring  of  the  organ  may  be  all  that  is  re- 
quired to  relieve  the  retention  and  to  give  the  stomach  a 
short  interval  of  repose.  The  complete  evacuation  also 
breaks  the  continuity  of  the  germ  growth.  Even  more  effec- 
tive is  complete  gastric  rest  for  a  few  days.  In  myasthenic 
retention  with   active  fermentation,  if  the   patient  be  put   to 


DIET.  221 

bed,  the  stomach  thoroughly  washed  out  and  daily  douched 
internally,  all  food  prohibited  by  the  mouth,  and  the  body 
nourished  exclusively  by  nutrient  enemata  for  from  three  to 
five  days,  the  result  is  often  remarkable.  With  this  plan  of 
treatment  should  be  combined  the  daily  use  of  the  hot  and 
cold  needle-spray  for  one  minute  over  the  abdomen  and 
lower  extremities,  external  cathodal  galvanization  with  large 
plate-electrodes,  and  faradization  of  the  abdominal  muscles. 
If  the  stomach  does  not  retract,  strychnin  in  full  doses  will 
prove,  in  some  cases,  a  valuable  aid.  This  short  systematic 
medication,  in  which  rectal  feeding  plays  an  essential  part, 
rarely  fails  to  control  the  fermentation  and  to  relieve  or  dimin- 
ish the  retention.  The  same  treatment  is  very  valuable  in 
myasthenic  stagnation. 

In  the  treatment  of  the  dynamic  affections  where  the  stom- 
ach is  morbidly  sensitive  and  irritable,  a  few  days  of  exclusive 
rectal  feeding  may  be  advisable.  A  good  result  is  often  thus 
obtainable  in  uncontrollable  vomiting,  in  hyperesthesia,  and 
in  adenohypersthenia  gastrica,  the  rectal  feeding  acting  as  a 
remedy  by  giving  absolute  rest  to  the  stomach  and  furnish- 
ing some  nourishment  to  the  body. 

In  the  treatment  of  obstinate  and  complicated  ulcer  of  the 
stomach,  rectal  feeding  may  be  used  to  supplement  or  to 
supplant  feeding  by  the  mouth.  Hemorrhage  and  local 
peritonitis  and  perforation  are  stringent  indications  for  exclu- 
sive rectal  feeding.  So  great,  indeed,  are  the  advantages  of  a 
few  days  of  gastric  repose  that  even  in  simple,  uncomplicated 
ulcer,  in  the  beginning  of  the  treatment,  or  intermittently 
during  the  cure,  rectal  feeding  might  be  more  frequently 
employed  with  benefit  and  without  the  least  danger. 

In  severe  acute  gastritis  and  in  the  hypersthenic  form  of 
chronic  gastritis,  the  incalculable  value  of  gastric  rest  for  a 
few  days  demands  the  employment  of  rectal  feeding.  Also 
in  the  diseases  of  the  stomach  which  are  not  compensated 
by  the  intestines,  and  when  too  little  food  is  digested  and  ab- 
sorbed, rectal  feeding  aids  in  the  maintenance  of  nutrition, 
particularly  where  the  large  bowel  is  healthy.  Some  good 
may  also  be  done  by  this  method  of  feeding  in  arresting  the 
progressive  inanition  of  carcinoma. 

4.  Not  only  the  diseases  of  the  stomach,  but  the  pozver  and 
state  of  other  organs,  should  be  kept  in  mind.  The  stomach 
decides  the  selection  of  the  diet  in  only  one  condition — viz., 
when  it  is  the  only  organ  diseased.  The  dietist  will  here  ex- 
perience little  difficulty  in  formulating  his  prescription  in  keep- 
ing with  the  indications  given  by   the  careful   application  of 


222  DISEASES  OF  THE  STOMACH. 

the   methods  of  investigation.     Unfortunately,  it  is  rare  that 
the  problem  is  so  simple  and  easy  of  solution. 

The  intestines  establish  digestive  compensation  in  the 
diseases  of  tiie  stomach.  Consequently,  be  the  intestines 
healthy  or  diseased,  they  are  never  silent  in  the  selection  of 
a  diet.  The  diet  in  a  diseased  stomach  with  normal  in- 
testines is,  so  far  as  the  intestines  are  concerned,  prophylactic. 
The  food  should  be  finely  divided  and  free  from  abnormal 
chemical,  physical,  or  living  irritants.  The  meats  should 
be  palatable  and  freed  from  indigestible  matter;  the  cereals 
should  be  finely  pulverized  and  thoroughly  cooked,  and  the 
fats  sweet,  and  those  most  digestible  should  be  selected.  No 
food  should  be  given  that  is  likely  to  undergo  fermenta- 
tion in  the  stomach,  or  to  throw  extra  work  on  the  intestines, 
or  to  force  them  to  work  at  a  disadvantage.  The  intestines 
should  be  as  closely  watched  and  favored  and  protected  as 
the  heart-muscle  in  valvular  lesions,  for  the  intestines  stand 
between  the  diseased  stomach  and  inanition. 

When  the  intestines,  as  well  as  the  stomach,  are  diseased,  the 
diet  should  be  regulated  in  accordance  with  the  digestive 
and  assimilative  power  of  the  alimentary  canal.  The  diet 
should  favor  the  weakest  point;  what  can  not  be  digested 
need  not  be  prescribed  ;  the  foods  should  be  selected  which 
have  the  best  chance  of  escaping  destructive  changes,  the 
physiological  action  of  which  on  the  diseased  digestive 
tube  is  most  favorable  to  their  digestion  and  absorption,  and 
the  therapeutic  effect  of  which  is  most  likely  to  be  beneficial. 
The  task  of  the  dietist  is  here  a  hard  one,  and  can  only  be 
done  by  precise  and  correct  directions,  by  close  observation, 
and  by  free  use  of  the  clinical  guides. 

The  diet  in  the  diseases  of  the  stomach  should  also  be 
modified  so  as  to  be  appropriate  to  any  other  organ  that  may 
be  diseased.  The  diseases  of  nutrition,  particularly  gout  and 
diabetes,  should  not  be  overlooked,  and  nephritis  often  forces 
a  compromise.  The  waste  products  of  the  carbohydrates  and 
fats  no  doubt  give  the  kidneys  less  work  to  do  than  those  of 
albumin,  which  latter  may  be  retained  in  the  blood  in  poison- 
ous quantities.  But  the  normal  products  of  albuminous 
catabolism  are  much  less  injurious  than  the  absorbed  pro- 
ducts of  gastro-intestinal  decomposition  and  some  forms  of 
fermentation.  The  first  requisite  of  any  diet  is  that  it  be 
digested  and  absorbed,  and,  consequently,  the  stomach  and 
intestines,  when  diseased,  always  exercise  a  controlling  influ- 
ence in  the  selection  of  a  proper  diet.  Other  diseases  may 
so  modify  a  diet  as  to  destroy  its  value  as  a  physiological 


DIET.  223 

remedy  in  the  treatment  of  the  diseases  of  the  stomach. 
The  remedial  influence  of  food  should  then  be  replaced  by 
other  forms  of  appropriate  medication. 

5.  The  finances,  habits,  and  peculiarities  of  the  patient  should 
be  considered.  In  selecting  a  diet  for  the  rich,  with  all  the 
luxuries  and  comforts  at  their  command,  the  foods  which  are 
to  furnish  nourishment  and  aid  in  the  cure  may  be  chosen 
from  the  best  in  the  market.  But  many  feel  the  sting  of 
poverty,  and  must  live  on  what  is  cheap.  The  practical  physi- 
cian will  order  the  foods  which  are  best  and  most  suitable 
under  the  circumstances. 

A  man's  stomach  is  often  what  he  makes  it.  It  readily 
becomes  the  slave  of  habit,  and  is  often  endowed  by  circum- 
stances with  peculiar  capabilities  and  weaknesses.  Foods 
agree  and  disagree  contrary  to  what  would  rationally  be 
expected.  These  results  of  training  and  these  individual 
peculiarities  should  not  be  rudely  disregarded,  and  the  patient 
ordered  to  eat  what  agrees  with  most  men  afflicted  with  the 
same  disease  ;  a  man  is  too  prone  to  order  others  to  eat 
what  he  himself  best  digests. 

6.  The  directions  should  be  complete  and  explicit,  and  shojild 
be  changed  to  meet  the  daily  indicatio)is.  It  is  only  when  it  is 
carefully  and  minutely  regulated,  and  changed  from  day  to 
day  to  meet  the  new  conditions,  that  the  value  of  the  dietetic 
treatment  of  the  diseases  of  the  stomach  becomes  so  striking. 
If  the  physician  be  content  with  writing  a  list  of  permitted 
and  forbidden  foods  and  drinks,  and  does  not  keep  the  patient 
under  control  and  observation,  no  permanent  benefit  is  likely 
to  be  conferred.  It  is  necessary  to  watch  the  evolution  of 
the  disease,  so  as  to  be  able  and  ready  at  the  right  moment  to 
make  the  suitable  changes  in  the  diet. 

In  writing  a  prescription,  it  is  usual  to  select  the  best  drugs 
for  the  special  case,  to  regulate  the  doses  according  to  the 
effects  desired,  and  to  order  them  to  be  taken  in  a  particular 
manner  at  regular  intervals,  until  it  is  evident  that  the  effects 
are  obtained.  The  principles  of  prescribing  a  diet  are  the  same. 
As  a  remedy,  the  diet  should  be  used  in  the  same  manner  as 
any  article  of  the  materia  medica. 

11.   SIGNS   OF   CORRECTNESS   OF    THE    PRESCRIBED 

DIET. 

The  diet  being  rationally  selected  in  accordance  with  the 
rules  already  given,  it  should  next  be  prescribed  and  con- 
trolled by  the  clinical  guides. 


224  DISEASES  OF  THE  STOMACH. 

If  the  diet  is  correct,  the  discomfort  of  which  the  patient 
complains  will  be  relieved.  There  is  soniethini^  radically 
wrong  with  a  diet  which  increases  the  subjective  symptoms, 
and  the  patient  will  be  the  first  under  the  circumstances  to 
protest.  When  the  diet  does  not  diminish  or  relieve  the  dis- 
comfort of  which  the  patient  is  conscious,  all  that  can  be  said 
is  that  the  diet  is  doing  no  harm.  The  correctness  of  the 
diet  is  proportionate  to  the  relief  afforded.  It  is  not  expected 
in  every  case  that  the  trouble  will  be  relieved  as  if  by  magic, 
but  the  sensations  of  the  patient,  where  no  indulgences  are 
taken,  form  a  rough  but  trustworthy  clinical  guide. 

A  correct  diet  will  usually  cause  no  loss  of  weight  and 
strength;  otherwise  the  first  requisite  of  a  diet — which  is  the 
maintenance  of  the  nutrition  of  the  body — is  not  fulfilled. 
But  not  rarely,  even  in  the  simple  diseases  of  the  stomach, 
the  diet  must  be  insufficient.  The  injury  done  to  the  organ- 
ism must  not  be  carried  so  far  as  to  outweigh  the  benefit  de- 
rived from  the  favoring  and  repose  of  the  stomach.  The 
diseases  of  the  stomach  with  a  tendency  to  emaciation,  par- 
ticularly the  motor  insufficiency  of  carcinoma,  should  never 
be  treated  by  a  reducing  diet,  for  here  the  organism  has  no 
power  to  regain  what  is  lost. 

If  the  symptoms  disappear  without  loss  of  weight,  the 
diet  is  correct,  and  should  not  be  changed  unless  it  is  neces- 
sary or  advisable  to  force  alimentation  in  order  to  improve 
the  state  of  nutrition.  If  there  is  no  loss  of  weight  or 
strength,  but  no  improvement  of  the  symptoms,  the  diet  is 
sufficient  but  not  remedial.  If  the  patient  feels  better,  but 
weight  is  being  lost,  the  diet,  except  in  cases  of  obesity,  is 
proper  but  insufficient.  A  diet  which  does  not  improve  the 
symptoms,  and  also  reduces  the  weight,  should  be  considered 
as  radically  wrong.  In  retention  and  carcinoma  it  may  not  be 
possible  to  arrest  the  emaciation  ;  the  symptoms  may,  however, 
be  improved  by  proper  diet  and  medication.  These  simple 
rules  are  excellent  clinical  guides. 

In  addition  to  the  sensations  of  the  patient  and  the  gain 
or  loss  of  stren";th  and  weight,  there  are  also  other  clinical 
guides  to  the  correctne.ss  of  the  dietetic  treatment.  Among 
these  are  certain  physical,  functional,  and  bacteriological  signs. 

The  abnormal  physical  signs,  in  so  far  as  they  are  depen- 
dent on  the  diet,  should  improve,  although  they  are  often  the 
expression  of  the  lesion  only.  An  increase  or  decrease  of 
myasthenia  can  be  recognized.  Gastric  flatulency,  occurring 
immediately  after  a  meal,  when  there  is  no  gastric  retention, 
is  due  to  swallowed  air,  and  if  the  stomach  is  much  distended 


DIE7\  225 

is  often  a  sign  of  myasthenia.  Under  these  circumstances, 
if  the  diet  is  suitable  to  myasthenia,  the  flatulency  is  not  a 
revealing  sign  of  a  dietetic  error ;  but  in  the  absence  of  gastric 
retention  and  colonic  stagnation  and  fermentation,  flatulent 
distention,  occurring  immediately  after  a  meal,  is  a  sign  of 
myasthenia,  and  it  should  be  at  once  considered  whether  the 
diet  is  not  physically  too  heavy,  or  too  large,  or  too  exciting. 
Overstimulation  of  a  myasthenic  stomach  produces  irregular 
and  often  painful  peristalsis  or  complete  relaxation.  The 
flabby  wall  yields  readily  to  the  expansibility  of  the  contained 
gas. 

Gastric  flatulency,  coming  on  some  time  after  a  meal,  may 
be  due  to  myasthenia,  to  gas-forming  fermentation,  or  to 
putrefaction.  Gastric  putrefaction,  except  as  an  accident,  is 
almost  unknown,  except  in  carcinoma  and  in  gastric  reten- 
tion, and  then  it  is  always  accompanied  by  fermentation. 
The  gas  in  the  stomach  is  either  swallowed,  regurgitated 
from  the  intestines,  or  formed  in  the  stomach  by  fermentation. 
(The  chemically-decomposed  carbonates  and  exhaled  gas 
from  the  blood  may  be  disregarded.)  The  cause  of  the 
flatulent  distention  may  be  readily  determined  by  using  the 
stomach-tube  or  by  giving  an  exclusively  meat  meal.  If  it 
be  found  due  to  fermentation,  the  diet  must  be  so  regulated 
as  to  avoid  or  control  this  abnormal  process. 

Flatulency  is  more  often  in  the  intestines,  and  when  abnor- 
mally increased  is  a  sign  of  increased  gas  formation  by  putre- 
faction and  fermentation,  or  of  this  process  combined  with 
myasthenia,  or  of  myasthenia  alone.  The  stools  and  urine 
should  be  examined  for  signs  of  putrefaction ;  if  negative, 
test  the  acidity  of  the  stools  and  prescribe  an  exclusive  meat 
diet  as  a  trial.  If  either  fermentation  or  putrefaction  is 
found,  the  appropriate  diet  and  medication  should  be  pre- 
scribed. If  neither  exists  in  excess,  the  diet  and  medication 
are  directed  against  the  myasthenia. 

The  influence  of  the  diet  as  a  remedy  is  revealed  by  the 
functional  signs.  If  the  gastro-intestinal  functions  are  im- 
proved thereby,  the  diet  is  correct.  If  the  functional  signs 
are  made  worse,  and  the  other  medication  is  not  responsible, 
the  diet  is  either  wrong  or,  as  regards  the  intestines,  an  en- 
forced compromise.  The  intestines  compensate  a  diseased 
stomach,  and  their  functional  activity  requires  careful  preser- 
vation. A  diet  which  does  not  maintain  the  functions  of  the 
intestines  in  their  integrity  is  always  regrettable,  but  is  some- 
times advisable  in. order  to  favor  a  diseased  stomach  tempo- 
raril\^  If  there  is  no  change  in  the  functional  signs,  the  diet 
15 


226  DISEASES  OF  THE  STOMACH 

is  either  a  failure  or  inactive  as  a  remed)-,  but  may  be  the 
best  tliat  is  possible  if  it  is  in  conforniit)-  with  the  other 
clinical  guides. 

The  bacteriological  signs  are  useful  not  only  in  diagnosis, 
but  also  in  the  selection  and  control  of  tlie  diet.  As  a 
clinical  dietetic  guide,  not  only  the  bacteriology  of  the 
stomach,  but  also  the  evidences  of  excessive  germ  activity  in 
the  intestines,  should  be  sought  in  the  stools  and  urine.  The 
diet  should  be  so  managed  as  to  control  the  excessive  germ 
growth  in  the  digestive  tube. 

Naturally,  the  curative  treatment  is  directed  against  the 
conditions  which  favor  the  excessive  germ  growth ;  but 
much  can  also  be  accomplished  by  a  proper  selection  and  by 
sudden  changes  in  the  diet  so  as  to  form  an  unfavorable  cul- 
ture soil.  Fermentation  and  putrefaction  reveal  themselves  in 
the  odor,  reaction,  and  composition  of  the  stools.  In  the  urine 
are  found  the  products  of  the  putrefaction,  and  of  these  pro- 
ducts the  one  of  most  importance  is  indican. 

The  value  of  the  quantity  of  the  aromatic  sulphates  in  the 
urine  as  a  clinical  guide  is  unquestionable.  The  quantity  of 
indican — which  may  be  taken  as  an  indicator — is  not  always 
proportionate  to  the  activity  of  intestinal  putrefaction,  but  is 
also  dependent  on  absorption.  Only  when  absorption  is 
good  is  it  a  guide.  A  negative  result  should  not  be  given  a 
positive  meaning. 

Intestinal  putrefaction  is  most  active  in  the  ileum  and  colon 
and  is  greatly  influenced  by  the  acidity  of  the  contents. 
This  acidity  is  due  to  two  factors — the  secreted  hydrochloric 
acid  and  the  organic  acids  of  fermentation. 

To  the  dietist,  the  two  most  important  circumstances  which 
influence  intestinal  putrefaction  are  the  acidity  of  the  gastric 
secretion  and  the  composition  of  the  diet. 

If  intestinal  and  gastric  fermentation  or  intestinal  putrefac- 
tion be  produced  or  increased  by  the  diet,  a  mistake  has  been 
committed,  and  the  proper  correction  should  be  made  at 
once.  Putrefaction  is  more  injurious  than  fermentation,  for 
it  produces  not  only  local  trouble,  but  also  serious  systemic 
intoxication.  Where  these  processes  already  exist,  their  de- 
crease is  the  clinical  sign  of  the  correctness  of  the  diet. 

By  the  daily  use  of  these  clinical  guides  the  diet,  rationally 
selected,  is  controlled  and  made  appropriate  to  the  individual 
case.  In  order  to  obtain  the  full  remedial  influences  of  food 
no  indulgences  should  be  permitted,  and  other  forms  of 
appropriate  medication  should  be  employed  at  the  same  time. 


PHYSICAL    REMEDIES.  22/ 

CHAPTER  111. 
PHYSICAL  REMEDIES. 

The  physical  remedies  which  are  used  most  extensively  in 
the  general  treatment  of  the  diseases  of  the  stomach  are 
water,  electricity,  and  massage.  To  these  should  be  added 
the  abdominal  belts  which  are  employed  to  give  proper  sup- 
port to  the  stomach. 

The  Uses  of  Water. — In  the  treatment  of  the  diseases  of 
the  stomach,  water  may  be  used  internally — as  a  drink,  or  to 
wash  out  the  stomach  or  to  spray  the  mucous  membrane  of 
the  stomach  ;   or  it  may  be  employed  externally. 

Water  is  continuously  eliminated  by  the  kidneys,  the  skin, 
the  lungs,  and  the  secretion  and  excretions  of  the  digestive 
system.  This  loss  is  constantly  supplied  by  absorption.  In 
health,  elimination  and  absorption  are  so  balanced  as  to  main- 
tain the  percentage  of  water  in  the  body  at  a  constant 
standard.  The  excessive  drinking  of  water  only  raises  the 
percentage  temporarily.  Elimination  rapidly  reduces  it  to 
the  normal  percentage,  which  is  about  63.  This  vital 
law  renders  it  possible  to  wash  out  the  system  by  the 
ingestion  and  absorption  of  large  quantities  of  this  solvent. 
The  use  of  very  large  quantities  of  hot  water  is  not  indicated 
by  disease  of  the  stomach.  Uricemia,  gout,  rheumatism,  and 
auto-intoxication,  may  demand  the  eliminating  action  of  water, 
and  these  troubles  may  be  associated  with  gastric  disease. 
Before  ordering  such  treatment  we  must  know  the  motor 
power  of  the  stomach,  which  determines  the  manner  of 
administration,  and  may  prohibit  the  use  of  excessive  quanti- 
ties of  water. 

A  diminution  of  the  quantity  of  water  causes  the  fat 
deposit  to  be  utilized  (Oertel),  while  an  increase  may  have  the 
opposite  effect.  In  water  insufficiency,  as  in  all  other  forms 
of  starvation,  the  body  is  forced  to  live  on  itself.  The  in- 
creased nitrogenous  elimination  after  the  ingestion  of  water 
in  excess  is  temporary,  and  has  been  attributed  solely  to  the 
more  thorough  removal  of  waste  tissue  products. 

The  action  of  plain  drinking  water  on  the  stomach  is 
dependent  on  the  quantity  and  the  temperature.  Mineral 
waters  are  employed  as  physiological  and  chemical  remedies, 
and  are  considered  in  the  fifth  and  sixth  chapters  of  this 
section   of  the   book.     Cold   water   is   an   intense  excitant  of 


228  DISEASES  OF  THE  STOMACH. 

secretion  when  taken  on  an  empty  .stomach,  and  tlie  action 
of  water  within  limits  becomes  less  intense  with  the  increase 
of  the  temperature.  Cold  water  remains  longer  in  the 
stomach  than  water  at  spring  temperature,  while  hot  water  is 
evacuated  very  rapidly  by  the  normal  stomach.  The  greater 
the  quantity  of  water  taken,  the  longer  it  remains  in  the  stom- 
ach ;  but  large  quantities  may  be  drunk,  without  propor- 
tionately delaying  evacuation,  by  drinking  it  in  sips.  The 
quantity  of  water  absorbed  from  the  stomach  is  exceedingly 
small.  Hot  water  excites  less  gastric  secretion,  is  more 
rapidly  evacuated  by  the  normal  stomach,  increases  the  flow 
of  bile,  is  a  better  solvent,  and,  consequently,  is  the  form  of 
water  most  useful  in  the  internal  hydrotherapy  of  certain 
gastric  troubles. 

The  soothing  effects  of  hot  water  are  sometimes  useful  in 
allaying  the  irritability  of  the  stomach,  and  are  a  valuable 
means  of  arresting  forms  of  vomiting.  In  excessive  secretion, 
and  in  digestive  superacidity  associated  with  normal  motor 
activity,  a  glass  of  hot  water,  sipped  slowly  an  hour  before 
meals,  is  a  simple  and  excellent  remedy. 

In  myasthenia  it  is  necessary  to  avoid  overloading  the 
stomach,  and  the  quantity  of  food  and  drinks  required  to 
maintain  the  balance  of  nutrition  must  be  so  introduced  as  to 
favor  the  weak  muscle  as  much  as  possible.  The  action  of 
the  diet  must  be  such  as  not  to  delay  or  make  difficult  its  evac- 
uation. In  addition  to  selecting  food,  finely  divided,  rapidly 
evacuated,  and  nutritious  in  small  bulk,  the  quantity  of  water 
taken  with  the  meal  must  be  limited.  The  remainder  of 
water  required  to  supply  the  needs  of  the  organism  may  be 
so  given  as  to  secure  a  therapeutic  effect.  In  myasthenia 
with  normal  or  diminished  secretion,  a  single  glass,  or  less, 
of  cold  water,  slowly  sipped  an  hour  before  each  meal,  often 
exerts  a  tonic  influence.  In  myasthenia  associated  with 
glandular  irritation  or  delayed  evolution  of  secretion,  a 
single  glass,  or  less,  of  hot  water,  an  hour  before  each 
meal,  has  an  undoubted  beneficial  action,  but  the  hot  water 
must  be  sipped  slowly  and  the  stomach  be  completely 
empty  before  the  time  for  the  meal.  In  myasthenia  the  total 
quantity  of  water  allowed  should  be  strictly  limited  to  that 
required  by  the  organism.  The  stomach  must  always  be 
empty  at  the  beginning  of  a  meal  and  never  overloaded  with 
fluids.  In  gastric  retention,  due  to  whatever  cause,  a  drink- 
cure  of  any  kind  whatsoever  is  absolutely  contraindicated, 
and  the  administration  of  hot  water  before  meals  is  obviously 
worse  than  useless.     Neither  should   very  hot  drinks  ever  be 


PHYSICAL    REMEDIES.  229 

given  in  continuous  supersecretion,  in  ulcer  with  a  tendency 
to  hemorrhage,  or  in  cancer  with  hemorrhage  or  with 
retention. 

The  chief  indication,  however,  for  the  drinking  of  hot 
water — natural  or  artificial — is  gastritis.  The  use  of  hot 
water  in  gastritis  should  be  more  accurately  limited,  and 
should  be  confined  to  cases  with  the  motor  function  still 
intact  and  capable  of  evacuating  in  one  hour  a  glass  of  hot 
water  slowly  sipped  on  an  empty  stomach.  It  removes  the 
excess  of  mucus  and  exerts  a  healing  and  soothing  influence 
directly  on  the  glandular  layer.  It  is  also  claimed  that  it 
prevents  excessive  fermentation,  but  so  long  as  there  is  no 
motor  insufficiency  there  is  no  other  organic  disease  of  the 
stomach  with  so  few  germs  as  are  found  in  gastritis.  Where 
the  fermentation  is  due  to  stagnation  or  retention,  the  drink- 
ing of  hot  water  is  contraindicated. 

Stomach  washing  is  "a  mechanical  remedy  that  demands 
very  special  indications  and  has  fallen  somewhat  into  dis- 
repute through  its  too  frequent  use  in  cases  where  it  can  serve 
no  good  purpose. 

The  employment  of  this  remedy  should  be  limited  to  three 
conditions:  (i)  Retention  or  stagnation  of  food  and  of  di- 
gestive products  ;  (2)  retention  of  excessive  secretions  ;  (3)  a 
rich  and  active  germ  growth. 

I.  There  can  be  no  question  as  to  the  value  of  the  remedy 
when  there  is  retention.  A  stomach  which  never  completely 
empties  itself  never  rests,  and  is  placed  in  a  most  unfavorable 
condition  for  regaining  its  lost  power.  The  retention  may 
be  due  to  obstruction  or  to  a  high  degree  of  myasthenia. 

In  simple  myasthenia  with  stagnation,  lavage  is  worse 
than  useless  where  there  is  no  gastric  fermentation.  If  em- 
ployed before  the  stomach  is  empty  it  robs  the  organism  of  the 
nourishment  which  without  interference  would  be  delivered 
eventually  to  the  intestines.  If  employed  afte-r  the  evacua- 
tion is  complete,  it  is  evident  that  no  advantage  is  gained.  In 
both  cases  it  only  stretches  and  irritates  a  weak  muscle  with- 
out improving  the  condition  of  the  mucous  membrane.  The 
morning  washing,  too,  is  here  useless,  for  the  stomach  is 
clean  and  empty  and  is  retracted ;  the  evening  washing  does 
no  good  and  relieves  no  symptoms. 

In  myasthenia  with  stagnation  of  the  severe  type  (the 
stomach  emptying  itself  during  the  night,  but  not  between 
meals),  accompanied  by  fermentation  simply,  the  stomach 
should  be  washed  out  before  going  to  bed  and  left  empty  until 


230  DISEASES  OF  THE  STOMACH. 

morning;  but  if  accompanied  by  fermentation  and  excessive 
secretion,  it  is  best  to  wash  out  the  stomach  before  the  even- 
ing meal. 

In  myasthenia  with  retention  the  circumstances  are  altered. 
The  stomach  never  empties  itself  completely,  and  is  too  ex- 
hausted to  retract.  Germs  find  a  rich  and  persistent  culture 
soil.  The  nervous  system  is  continuously  excited  and  the 
secreting  cells  accumulate  neither  energy  nor  products.  The 
most  important  indication  is  to  give  the  organ  rest  by  arti- 
ficially emptying  and  cleaning  it.  In  our  opinion,  the  even- 
ing washing,  as  a  rule,  is  decidedly  best  in  nnasthenic 
retention,  on  account  of  the  rest  which  is  thus  secured  for 
the  organ  and  the  patient  and  the  long  break  made  in  the 
germ  growth.  The  evening  meal  must  then  be  light,  such 
as  is  quickly  digested  and  emptied  by  the  normal  stomach 
into  the  duodenum.  Between  four  and  five  hours  later  the 
stomach  may  be  washed  out  and  left  completely  empty  until 
morning;  but  if  there  be  little  fermentation  it  is  better  to 
do  lavage  in  the  morning  and  enable  digestion  and  absorption 
to  proceed  during  the  night.  The  operation  should  be  per- 
formed daily  until  the  bacterial  growth  is  checked  and  the 
fermentation  controlled,  never  introducing  more  than  a  pint 
of  water  before  allowing  it  to  flow  out,  continuing  the  opera- 
tion until  the  stomach  is  clean,  making  sure  that  the  water 
does  not  accumulate  by  comparing  the  quantity  withdrawn 
each  time  with  that  introduced,  and  leaving  the  stomach  com- 
pletely empty.  After  the  first  week  lavage  ever\'  second 
evening  will  often  suffice. 

In  myasthenic  retention  accompanied  by  excessive  secre- 
tion and  fermentation,  the  stomach  should  be  washed  out 
twice  daily — before  the  evening  meal  and  in  the  morning 
before  breakfast.  This  plan  controls  the  fermentation  and 
enables  the  system  to  utilize  the  greatest  possible  quantity 
of  food.  If  the  body,  however,  is  well  nourished,  the  stom- 
ach should  be  washed  out  before  retiring  and  left  empty 
so  as  to  give  the  organ  functional  rest  and  protection  from 
irritation  during  the  night. 

In  obstructive  retention  there  is  uncompensating  muscular 
hypertrophy.  The  muscle  has  become  stronger  and  then 
failed.  There  is  the  same  stringent  indication  for  washing  out 
the  stomach  as  in  myasthenic  retention.  The  best  time  for 
performing  the  operation  varies.  If  the  obstruction  be  such 
that  it  can  be  overcome  by  increased  muscular  power, — as  is 
frequently  the  case  in  gastric  displacement,  in  traction  con- 
striction, and  in  relative  muscular  insufficiency, — the  operation 


PHYSICAL    REMEDIES.  23  I 

should  be  perfoniied  in  the  evening.  In  obstructive  retention 
due  to  an  organic  lesion  the  operation  can  only  be  palliative, 
and  it  may  be  wisest  to  secure  as  much  nourishment  as  possible 
for  the  body  by  making  the  stomach  work  at  night.  The 
stomach  should  then  be  washed  out  in  the  morning  ;  or  if 
there  be  active  fermentation  or  excessive  secretion,  lavage 
should  be  done  both  before  the  evening  meal  and  before 
breakfast. 

2.  The  retention  of  excessive  secretion  is  a  condition  which 
may  be  rationally  treated  by  lavage.  The  retained  secretion 
may  be  the  product  of  the  general  or  specific  activity  of  the 
glands  of  the  stomach. 

Specific  secretion,  normally  intermittent,  may  become  con- 
tinuous. This  by  no  means  rare  trouble  is  usually  associated 
with  myasthenia.  The  muscle  seems  often  inactive  rather 
than  weak,  and  the  condition  is  analogous  to  the  motor  in- 
sufficiency associated  with  excessive  lactic  acid  formation  in 
malignant  disease.  The  glands  of  the  organ  get  no  rest  and 
are  continuously  irritated  by  their  own  products.  It  is  a 
good  plan  to  wash  out  such  a  stomach  with  plain  warm  water 
until  clean,  in  the  morning  before  anything  has  been  eaten, 
and  then  with  a  i  :  1000  solution  of  nitrate  of  silver,  the 
stomach  being  left  empty  for  at  least  an  hour  after  the  opera- 
tion. 

The  general  mucous  secretion  may  be  excessive  and  may  ac- 
cumulate in  the  stomach  in  large  quantity.  A  coating  of  mucus 
is  normal  and  is  a  necessary  protection,  but  when  the  mucus 
accumulates,  be  it  swallowed  or  excessively  secreted  by  the 
stomach,  removal  is  necessary  in  order  to  avoid  the  chemical 
and  physiological  disturbance  caused  by  it.  The  stomach 
should  be  washed  clean  and  prepared  to  offer  fresh  secretions 
to  the  ingested  food.  It  is  well  to  wash  out  the  stomach 
in  the  morning  before  breakfast  with  a  warm  alkaline  solution. 

3.  Lavage  may  be  employed  to  get  rid  of  a  very  active 
germ  growth  even  when  there  is  no  retention.  Through 
survival  of  the  fittest,  a  particular  micro-organism,  or  a  par- 
ticular class  of  them,  as  revealed  by  the  bacteriological  signs, 
may  become  established  in  the  stomach  in  virulent  activity. 
Washing  the  stomach  in  the  evening  with  large  quantities  of 
water  (medicated,  if  desired)  will  aid  in  rendering  it  sweet. 
Lavage  is  most  frequently  required  for  this  purpose  in  car- 
cinoma and  in  acute  indigestion  associated  with  fermentation. 

The  technic  of  stomach  washing  is  very  simple.  Two 
methods  are  in  common  use.  A  funnel,  to  which  is  attached 
a  piece  of  rubber  tubing  about  2j/  feet  long,  is  connected  by 


232 


DISEASES  OF  THE  STOMACH. 


a  short  glass  tube  with  the  previously  introduced  stomach- 
tube,  or  the  whole  instrument  may  be  made  in  one  piece. 
A  pint  of  warm  water  is  poured  into  the  funnel,  which  is 
raised  above  the  mouth,  and  the  water  gently  flows  in. 
Before  the  funnel  is  completely  empty  it  is  quickly  lowered 
below  the  level  of  the  stomach,  and  by  siphonage  the  fluid 
is  withdrawn.  The  quantity  of  fluid  withdrawn  is  noted 
and  compared  with  the  quantity  introduced,  and  the  solid 
constituents  should  also  receive  our  attention.  The  fluid  is 
then  emptied  into  the  receptacle  and  the  procedure  repeated 


Fig-  13-— The  simi>le  apparatus  of  Somervail  (1823). 

until  the  viscus  is  clean.  The  last  drop  possible  must  be 
removed  from  the  stomach  by  expression  before  the  tube  is 
withdrawn,  so  as  to  leave  the  organ  empty.  The  introduc- 
tion of  a  small  quantity  of  water  at  a  time,  the  avoidance  of 
a  strong  inflow  and  of  the  accumulation  of  water  in  the 
stomach,  and  as  complete  evacuation  as  possible  at  the  end 
are  common  rules  which  become  imperative  when  there  is 
myasthenia. 

The  second  method  is  with  a  receptacle  placed  above  the 
head.     This  receptacle  is  graduated  and   contains  the  water, 


V    ""  ^ 


Fig.  14.— Friedlieb's  apparatus  for  lavage  and  expression. 


233 


Fig.  15.— The  Leube-Rosenthal  apparatus  for  lavage. 


^34 


DISEASES  OF  THE   STOMACH. 


and  from  tlie  bottom  runs  a  soft  rubber  tube  to  connect  with 
one  prong  of  a  Y-shaped  connecting  glass  piece.  A  second 
piece  of  rubber  tubing  is  attached  to  the  second  correspond- 
ing prong,  and  ends  in  a  graduated  receptacle.  On  each  of 
these  tubes  is  fastened  a  clamp.  The  apparatus  is  connected 
with  the  introduced  stomach-tube,  and  is  then  ready  for  use. 
The  water  is  allowed  to  flow  into  the  stomach  in  the  desired 
quantity,  while  the   outflow    tube  is    closed.      This    is    next 


ecl-jon . 


Fig.  16. — Rosenheim's  intragastric  douche  tube. 

opened  and  the  feeding  tube  cut  off.  The  contents  of  the 
stomach  are  aspirated  automatically,  and  the  procedure  is 
repeated  until  the  stomach  is  clean,  when  the  tube  may  be 
withdrawn  after  the  stomach  is  completely  emptied  by  ex- 
pression. If  expression  alone  be  inefficient,  it  must  be  aided 
by  the  position  method. 

The  intragastric  douche  or  spray  is  more  beneficial  in  some 
of  the   diseases    of  the   stomach    than   lavage.      The  spray 


PHYSICAL    REMEDIES.  235 

(Einhorn)  possesses  the  advantage  of  distending  the  stomach 
so  that  the  plain  or  medicated  water  can  be  brought  into 
contact  with  all  parts  of  the  mucous  membrane.  The  douche 
is  the  form  which  we  prefer,  but  after  the  introduction  of  the 
tube  the  stomach  should  be  moderately  inflated  with  air 
before  the  water  is  allowed  to  flow  in.  The  tube  employed 
is  the  ordinary  stomach-tube,  which  is,  however,  provided 
with  a  small  end-opening  and  nine  smaller  openings  on  the 
sides.  The  edges  of  the  openings  should  be  rounded,  and 
their  combined  caliber  should  be  a  little  less  than  the  caliber 
of  the  tube. 

The  douche  is  of  service  to  arouse  peristalsis  (cold  water), 
to  increase  secretion  (teaspoonful  of  salt  to  a  quart  of  water), 
to  diminish  secretion  and  allay  irritability  (nitrate  of  silver, 
I  :  2000-5000),  to  excite  the  appetite  (weak  quassia  infusion), 
and  to  disinfect  the  mucous  membrane  (permanganate  of 
potash,  I  :  5000).  The  douche  is  employed  when  the  stomach 
is  clean  and  empty,  and  plain  water  is  used  before  and  after 
the  introduction  of  the  medicated  solution,  which  should  all 
be  removed  from  the  stomach. 

Water  may  be  used  externally  to  exert  an  action  on  the 
nervous  system,  on  nutrition,  on  the  temperature  of  the  body, 
and  on  the  various  functions.  Indirectly,  many  of  these 
procedures  influence  digestion  favorably,  but  the  description 
must  be  brief  and  limited  to  the  uses  of  water  in  the  treat- 
ment of  the  diseases  of  the  stomach.  This  constitutes  a 
special  and  important  division  of  hydrotherapy. 

The  employment  of  any  means  as  a  remedy  is  based  on 
its  physiological  action.  Hydrotherapy,  in  addition  to  its 
general  uses,  may  be  employed  to  produce  particular  effects 
on  particular  organs.  It  is  our  object  to  describe  how  the 
action  of  water  may  be  utilized  in  the  treatment  of  the  dis- 
eases of  the  stomach,  be  it  our  purpose  to  produce  a  par- 
ticular effect  on  the  nerve  supply,  on  peristalsis,  on  the  blood 
supply,  or  on  secretion.  In  private  practice  the  available 
methods  are  few  and  we  seldom  advise  more  than  two — 
varieties  of  the  compress  and  of  the  douche. 

The  compress  may  be  used  hot,  cold,  or  of  the  tempera- 
ture of  the  body. 

The  action  of  combined  heat  and  moisture  applied  over 
the  stomach  is  sedative — soothing  the  nerve  supply,  quieting 
peristalsis  and  spasm,  and,  when  used  for  a  long  period,  pro- 
moting the  resolution  of  chronic  inflammation.  The  hot 
compress  is  very  beneficial  in  cardialgia,  in  spasm  of  the 
orifices  and   of  the  body   of  the   stomach,  in    hyperesthesia 


236  DISEASES  OF  THE  STOMACH. 

gastrica.  and  in  similar  conditions  where  sedation  is  indicated. 
The  prolonged  use  of  hot  applications  over  the  stomach  is 
also  beneficial  in  ulcer  (no  recent  hemorrhage)  and  in  chronic 
gastritis,  but  these  applications  do  harm  in  acute  gastritis 
and  are  dangerous  in  ulcer  accompanied  by  hemorrhage. 
The  digestion  of  very  weak  and  emaciated  patients  is  im- 
proved by  moderately  hot  applications  over  the  stomach 
during  the  digestive  period. 

The  methods  of  employing  combined  heat  and  moisture 
are  numerous.  Towels  wrung  out  of  hot  water  and  hot 
poultices  are  most  commonly  ordered  ;  but  the  loss  of  heat 
and  the  necessit\^  of  frequent  re-applications  render  these 
methods  uncertain  in  their  action  and  inconvenient.  It  is 
best  to  use  an  abdominal  coil  through  which  hot  water  flows 
constantly.  Beneath  the  coil,  over  the  abdomen,  is  placed  a 
piece  of  flannel  wrung  out  of  hot  water,  evaporation  being 
prevented  by  covering  the  whole  with  an  impermeable  tissue. 

The  cold-water  application  is  antiphlogistic,  and,  when 
long  continued,  is  also  sedative.  The  most  important  uses 
of  cold  applications  are  to  control  acute  inflammation  (peri- 
gastritis) and  to  aid  in  the  arrest  of  gastric  hemorrhage. 
The  cold  compress  is  a  most  efficacious  remedy  in  the  treat- 
ment of  digestive  vomiting,  and  it  is  also  beneficial  in  both 
acute  and  chronic  gastritis. 

The  cold-water  may  be  applied  by  means  of  wet  towels  or 
an  ice-bag  over  a  wet  towel,  or  by  means  of  ice-water  run- 
ning through  an  abdominal  coil.  To  obtain  the  beneficial 
action  of  the  cold  compress  it  is  necessar\'  that  the  local 
action  produce  an  active  hyperemia  of  the  skin.  In  the  neu- 
rasthenic and  anemic,  and  in  very  weak  patients,  the  severe 
cold  often  produces  passive  congestion  of  the  skin,  and  the 
action  is  injurious.  To  avoid  this  injury  and  action  it  is  often 
necessary  to  place  a  rubber  tube  across  the  abdomen  and 
beneath  the  coil,  and  through  this  tube  hot  water  is  kept 
constantly  running  (Winternitz).  Whenever  the  disturbances 
against  which  the  compress  or  local  applications  are  directed 
are  digestive,  the  applications  should  be  made  half  an  hour 
before  meals,  and  should  be  continued  during  the  period  of 
digestion. 

The  Priessnitz  compress,  while  applied  cold  or  warm,  is  in 
reality  a  method  of  using  water  at  the  temperature  of  the 
body.  It  is  sedative,  soothing,  antiphlogistic,  and  hypnotic 
in  its  influence,  and  it  may  be  employed  with  a  good  prospect 
of  benefit  in  all  the  painful  diseases  of  the  stomach. 

The  Priessnitz  compress  may  be  applied  in  several  ways. 


PHYSICAL    REMEDIES.  237 

One  end  of  a  piece  of  flannel  which  is  broad  enou<jh  to  cover 
the  abdomen  and  long  enough  to  go  around  the  body  and 
twice  over  the  abdomen  is  wet  in  water  of  the  desired  tem- 
perature, and  the  bandage  is  applied  and  pinned  in  place.  Or 
a  towel  may  be  wrung  out  of  cold  water,  placed  over  the 
abdomen,  covered  with  an  impermeable  tissue,  and  held  in 
position  by  a  flannel  bandage  encircling  the  body.  The  im- 
permeable tissue  prevents  drying  and  lessens  the  chilling 
action  of  the  cold.  The  compress  may  be  worn  day  and 
night,  and  should  be  changed  twice  during  the  twenty-four 
hours. 

In  many  of  the  diseases  of  the  stomach  the  abdominal 
sympathetic  is  depressed  and  irritable.  Neurasthenia  gastrica 
is  a  disease  which  affects  chiefly  the  nerves  of  the  stomach. 
Many  other  diseases  of  the  stomach,  both  organic  and  dy- 
namic, can  be  favorably  influenced  by  giving  tone  to  the  nerve 
supply,  and  hydrotherapy  furnishes  the  most  active  remedy 
for  the  realization  of  this  object.  We  refer  to  a  special  form 
of  the  needle-spray. 

The  intensity  of  the  action  of  water  on  the  nervous  system 
is  dependent  on  the  temperature  of  the  water,  on  the  impres- 
sionability of  the  patient,  on  the  mechanical  excitation  of  the 
nerve  endings,  and  on  the  location,  extent,  and  duration  of 
the  application.  The  further  the  temperature  of  the  water  is 
above  or  below  the  indifferent  point,  the  greater  is  the  ex- 
citation. Consequently,  a  fine  needle-spray  momentarily  ap- 
plied under  moderately  high  pressure,  consisting  alternately  of 
hot  and  cold  water,  and  extended  over  the  area  of  distribu- 
tion of  all  the  nerves  connected  with  the  centers  controlling  the 
stomach,  exerts  a  most  powerful  action  on  this  organ.  The 
needle-spray,  applied  in  the  manner  which  is  here  recom- 
mended, increases  the  activity  of  blood  circulation  in  the 
spinal  centers  and  in  the  mucous  membrane  of  the  stomach, 
and  thus  relieves  their  congestion  and  improves  their  nutri- 
tion, excites  peristalsis  and  causes  the  stomach  to  contract 
firmly  on  its  contents,  and  restores  normal  secretion  and  tones 
the  abdominal  sympathetic,  as  does  no  other  single  remedy. 

The  needle-spray  should  be  used  in  the  following  manner, 
varying  the  temperature  of  the  water,  the  hydrostatic  pres- 
sure, and  the  duration  of  the  bath  so  as  to  be  appropriate  to 
the  individual  case.  The  chest  should  be  protected  during 
the  application,  which  should  not  extend  above  the  level  of 
the  lower  end  of  the  sternum.  The  temperature  of  the  water 
maybe  as  high  as  95°  F.  and  as  low  as  60°  F.  The  hot 
water  is  first  used,  and  then,  rapidly  changing  without  gradua- 


238 


DISEASES  OF  THE  STOMACH. 


tion,  the  cold  water  is  employed.  The  application  is  made 
with  the  hand  nozle,  revolving  the  spray  for  ten  to  twenty 
seconds  over  the  abdomen,  and  then  for  the  same  time  over 
the  front  and  then  the  back  of  the  lower  extremities.  The 
hot  and  the  cold  spray  require  only  one-half  to  one  minute 
each  for  their  application.  The  douching  is  followed  by 
rapid  drying,  brisk  rubbing,  and  immediate  dressing.  The 
stomach  should  be  emptv  when  the  bath  is  taken. 

The  Uses  of  Electricity. — Electricity  is  one  of  the  most 
useful  of  the  physical  remedies    in   diseases   of  the  stomach. 


Fig.  17. — A,  Rosenheim's  intragastric  electrode;  B,  VVegele's  spiral  electrode  covered 
with  rubber  tubing,  to  be  used  in  the  ordinary  stomach-tube. 


Each  physician  has  his  own  favorite  methods  of  employing 
it.  Only  those  will  be  described  which  in  our  own  hands 
have  given  the  best  results. 

Electricity  may  be  applied  internally  or  externally.  The 
internal  use  is  advisable  in  one  disease  and  one  condition — 
myasthenia — when  the  patient  is  accustomed  to  the  use  of  the 
tube.  Here  the  internal  application  would  seem  to  be  more 
powerful  than  the  external ;  how  much  of  the  additional  benefit 
is  due  to  the  more  vivid  impressions  and  suggestions  it  is  very 
hard  to  estimate.     The  intrasfastric  electrode  of  Rosenheim  is 


PHYSICAL    REMEDIES.  239 

a  very  good  instrument.  Einhorn  has  invented  a  capsule 
electrode  which  is  to  be  swallowed.  The  best  intragastric 
electrode  is  the  one  recommended  by  Wegele.  It  consists  of 
a  stomach-tube  through  which  runs  a  removable  spiral  con- 
ductor. The  instrument  can  be  kept  clean  and  can  be  used 
to  wash  out  the  stomach,  to  introduce  the  water  which  serves 
as  the  intragastric  electrode,  and  to  remove  the  water  after 
the  sitting.  The  external  method  consists  in  the  use  of  one 
or  more  forms  of  electricity  in  a  particular  manner — general 
faradization,  central  galvanization,  and  the  local  use  of  the  two 
currents.     Each  method  has  its  effects  and  its  indications. 

The  effect  of  the  galvanic  and  faradic  currents  on  the  secre- 
tions of  the  stomach  may  be  considered  well  established  by 


Fig.  iS. — Einhorn's  cajisule  electrode. 

experiments,  first  on  the  dog  and  then  on  man,  and  by  the 
analysis  of  the  gastric  secretion  thus  excited  and  obtained 
by  the  aid  of  the  stomach- tube.  After  the  use  of  a  moder- 
ately strong  current  for  about  ten  minutes,  20  or  30  c.c.  of 
gastric  juice  may  be  obtained,  rich  in  all  the  elements  of 
specific  secretion.  Secretion  may  be  excited  both  by  external 
galvanization  and  by  internal  faradization.  The  motor  func- 
tion may  also  be  notably  excited — the  contractions  being 
tonic  or  peristaltic  according  to  the  strength  of  the  current 
and  the  mode  of  application.  Some  deny  that  electricity 
excites  contractions  of  the  stomach.  Meltzer  laid  bare  the 
stomach  of  an  animal  and  applied  the  electrode  directly  to  its 


240  DISEASES  OF  THE  STOMACH. 

wall.  Faradization  produced  tonic  contraction  only  when  the 
electrode  was  near  the  pylorus;  over  the  fundus  the  result 
was  negative.  With  one  electrode  over  the  stomach  and  with 
the  other  either  over  the  spine  or  within  the  stomach,  no 
contraction  of  the  stomach  could  be  excited ;  but  these  ex- 
periments were  made  on  anesthetized  animals  during  shock. 
In  spite  of  the  denials  of  some  clinicians,  there  is  no  doubt 
that  electricity  does  produce  tonic  contraction  and  peristalsis 
of  the  human  stomach.  We  have  seen  both  galvanization 
and  faradization  cause  gastric  splashing  to  cease.  When 
patients  have  thin  abdominal  walls,  we  have  seen  and  felt  the 
peristaltic  contractions  of  the  stomach  produced  by  external 
galvanization,  and  these  patients  were  not  affected  by  peris- 
taltic unrest  (tormina  ventriculi).  A  glass  of  water,  the  test- 
breakfast,  and  the  test-dinner  are  evacuated  earlier  than 
normal  by  the  electrified  stomach.  The  effects  of  faradiza- 
tion and  negative  polar  galvanization  are  greatest,  both  on 
secretion  and  on  the  movements  of  the  stomach,  after  they 
have  been  employed  for  several  successive  days. 

Electricity  may  also  promote  absorption,  and  is  the  one 
direct  remedy  which  e.xcites  this  function  through  its  influ- 
ence on  the  vasomotor  nerves  and  the  cells  under  the  control 
and  activity  of  which  the  process  goes  on. 

But  electricity  is  not  only  valuable  on  account  of  its 
action  on  the  secretory,  motor,  and  absorptive  functions  of  the 
stomach.  It  can  exert  a  favorable  influence  on  the  general 
sensations  of  the  stomach,  while  it  is  ver\-  doubtful  whether 
it  has  any  direct  action  on  the  special  sensations  or  the 
appetite. 

This  remed}'  also  possesses  an  undoubted  trophic  action, 
which  may  be  utilized  in  the  treatment  of  the  chronic  ana- 
tomical diseases  of  the  stomach. 

Contraindications. — The  contraindications  to  the  employ- 
ment of  electricit)'  in  any  form  do  not  seem  to  have  attracted 
much  attention.     The  remedy  may  be  harmful  or  useless. 

1.  It  can  only  do  harm  in  acute  gastritis.  It  disturbs  the 
organ  when  rest  is  imperatively  demanded. 

2.  Electricity  of  high  density  does  no  perceptible  good  in 
severe  degrees  of  mj-asthenia.  It  acts  in  the  same  manner 
as  an  excitant  diet  would  under  the  circumstances. 

3.  The  remedy  should  not  be  used  during  the  active  period 
of  digestion.  Theoretically,  it  would  seem  plausible  that  the 
functions  of  the  stomach  might  be  aided  in  the  performance 
of  digestive  work  ;  but  practically  the  result  of  the  combined 
action   of  the  contents  and  of  the  remedy  can   not   be   con- 


PHYSICAL    REMEDIES.  24I 

trolled.  Electricity  may,  however,  be  given  in  myasthenia 
near  the  end  of  the  digestive  period. 

4.  A  recent  gastric  hemorrhage  is  a  contraindication. 
Neither  should  it  be  employed  in  diseases  of  the  stomach 
commonly  associated  with  hemorrhage.  Chronic  indolent 
ulcer  may,  however,  form  an  exception  where  hemorrhage  is 
not  favored  by  the  light  hyperemia  which  accompanies  the 
gentle  electrization  of  the  vagosympathetic  with  a  view  to 
obtaining  a  trophic  influence. 

We  do  not  believe  in  the  nihilism  which  claims  that  elec- 
tricity acts  solely  through  suggestion,  or  not  at  all.  This 
may  be  true  when  the  remedy  is  used  without  selection, 
method,  or  purpose.  The  physiological  action  of  electricity 
and  therapeutic  experience  should  guide  us  in  the  choice  and 
manipulation  of  the  electrodes  and  in  the  determination  of 
the  form,  strength,  and  density  of  the  currents  and  of  the 
duration  and  frequency  of  the  sittings. 

The  best  electrodes  are  the  nickel-plated  ones,  with  a  half- 
inch  thickness  of  sponge  covered  with  linen.  The  electrodes 
are  moistened  in  warm  water.  The  supply  should  be  large 
enough  to  enable  us  to  use  the  requisite  current  strength  and 
density  and  to  apply  them  in  the  proper  manner — continuous, 
interrupted,  stable,  or  mobile. 

The  density  of  the  current  is  represented  by  a  fraction, 
the  numerator  of  which  is  the  current  strength  in  milliam- 
peres  and  the  denominator,  the  surface  area  of  the  active 
electrode  in  square  centimeters.  The  "active  electrode  "  is 
the  one  over  the  point  of  greatest  excitation,  or  over  the  central 
nervous  system.  If  both  the  electrodes  be  over  indifferent 
points,  the  mean  surface  area  of  the  electrodes  is  taken.  A 
current  density  of  2^  should  not  be  exceeded  in  the  electric 
treatment  of  the  diseases  of  the  stomach,  and  when  the  active 
pole  is  over  the  spine  or  neck  it  should  not  be  greater 
than  3^0".  The  selection  of  the  poles  in  the  employment  of 
faradism  is  of  no  consequence ;  but  galvanism  possesses  a 
decided  polar  difference,  the  negative  pole  being  exciting  and 
the  positive  pole  sedative.  To  obtain  the  pure  polar  influence 
of  the  anode,  only  mild  currents  should  be  used,  and  care 
should  be  exercised  in  turning  on  and  off  the  currents.  Begin 
at  zero  and  gradually  and  slowly  increase  to  the  desired 
strength  ;  and  at  the  end  of  the  treatment  the  strength  of 
the  current  must  be  decreased  to  zero  in  the  same  manner 
before  the  firmly-held  electrodes  are  removed. 

The  duration  of  the  sittings  should  be  regulated  according 

to  the  effect  desired.     Short  applications  are  most  generally 
16 


242  DISEASES  OF  THE   STOMACH. 

useful,  and  should  never  be  so  prolonged  as  to  fatigue  the 
excited  part.     Exhaustion  is  no  remedy. 

The  frequency  of  the  sittings  is  variable.  In  the  painful 
affections  the  quieting  influence  of  the  anode  may  be  required 
several  times  a  day,  and  in  the  chronic  diseases  daily  or 
weekly,  and  the  electric  treatment  should  be  continued  as 
long  as  it  is  beneficial. 

Electricity  may  be  used  to  produce:  (i)  Excitation;  (2) 
sedation  ;  and  (3)  a  trophic  influence.  It  may  consequently  be 
employed  in  the  treatment  of:  (ij  Asthenia  gastrica  ;  (2)  hy- 
persthenia  gastrica  ;  and  (3)  forms  of  gastritis  and  of  ulcer. 

1.  The  Electrical  Treatment  of  Asthenia  Gastrica. — Neuras- 
thenia gastrica  may  or  may  not  be  associated  with  general 
neurasthenia,  and,  consequently,  the  treatment  may  be  both 
local  and  general  or  local  only. 

The  controlling  indication  is  gentle  excitation  of  the  vago- 
sympathetic. For  this  purpose  two  local  methods  may  be 
employed — the  one  indirect,  through  the  connections  of  the 
sympathetic  with  the  spinal  ner\es,  and  the  other  more  direct, 
through  the  cervical  sympathetic  vagi  connections  and  the 
gastric  fibers  running  in  the  cord  from  the  cranial  cavity. 
For  this  purpose  local  galvanization  or  central  galvanization 
may  be  employed. 

A  favorite  method  is  a  modification  of  the  one  recom- 
mended by  von  Ziemssen.  Two  large  plate  electrodes  are  em- 
ployed with  a  surface  area  of  300  sq.  cm.  each.  One  is  placed 
over  the  epigastrium,  and  e.xtends  from  the  pylorus  across 
the  abdomen  to  the  left,  covering  the  triangular  area  of  the 
stomach  in  contact  with  the  abdominal  wall,  which  is  marked 
by  the  lower  border  of  the  left  lobe  of  the  liver,  the  left 
costal  border,  and  the  line  of  the  greater  curvature.  This 
electrode  is  attached  to  the  negative  pole,  the  object  being  to 
obtain  the  polar  e.xciting  influence.  The  other  electrode, 
attached  to  the  positive  pole,  is  placfed  over  the  fundus,  and 
extends  to  the  left,  toward,  but  not  over,  the  vertebral  column. 
The  edges  of  the  electrodes  should  be  about  an  inch  apart. 
The  current  strength  should  never  exceed  15  milliamperes, 
which  gives  an  electric  density  of  tj^j.  The  electrodes  sliould 
be  well  moistened  and  held  in  firm  contact  with  the  body. 
The  current  should  be  turned  on  rapidly,  allowed  to  flow 
constantly  for  about  ten  minutes,  and  should  be  shut  off" 
suddenly.  It  is  not  advisable  to  begin  with  a  stronger  cur- 
rent than  five  milliamperes  (D  = -gJ^),  nor  to  continue  the 
strongest  permissible  current  (15),  when  it  is  used,  more  than 
a  few  minutes. 


PHYSICAL    REMEDIES.  245 

A  second  local  method,  which  may  be  alternated  with  the 
above,  is  with  the  roller  attached  to  the  negative  pole.  The 
100  sq.  cm.  anode  is  placed  to  the  left  of  the  dorsal  spine.  The 
current  strength  should  be  just  sufficient  to  excite  painless 
contractions  of  the  abdominal  muscles,  and  is  usually  about 
three  milliamperes.  The  roller  is  moved,  in  firm  contact, 
about  25  times  from  the  fundus  to  the  pylorus,  along  the 
axis  of  the  stomach,  and  back  again  without  lifting  it  from 
the  abdomen,  and  about  25  slow  strokes  are  made  from  above 
downward  over  the  area  of  the  stomach. 

The  first  method  influences  the  large  sympathetic  ganglia 
and  the  second  excites  more  strongly  the  intramural  ganglia 
of  the  stomach.  These  methods  should  be  employed  once  or 
twice  a  week.  The  object  will  be  defeated  by  meddlesome 
activity.  If  there  be  general  neurasthenia,  cervicogastric  gal- 
vanization may  be  used  at  the  same  sitting.  An  electrode  of 
100  sq.  cm.  is  placed  over  the  triangular  contact  area  of  the 
stomach  and  attached  to  the  negative  pole.  The  other  elec- 
trode, of  50  sq.  cm.,  and  attached  to  the  positive  pole,  is  placed 
over  and  between  the  fifth  and  seventh  cervical  vertebrae.  The 
moist  electrodes  are  firmly  held  in  this  position  and  the  current 
is  very  slowly  turned  on  ;  it  should  never  exceed  one  milli- 
ampere  in  strength.  The  positive  electrode  is  now  slowly 
moved  to  the  side  of  the  neck,  while  firm  contact  is  main- 
tained, the  upper  border  passing  just  below  the  mastoid  pro- 
cess, and  the  electrode  momentarily  arrested  when  it  has 
reached  the  anterior  border  of  the  sternocleidomastoid. 
From  this  location  it  is  moved  downward  to  the  clavicle  and 
along  its  upper  border  back  to  the  starting-point.  The  same 
circuit  is  then  made  on  the  opposite  side,  each  consuming 
about  one  minute,  which,  with  one  minute  over  the  spine, 
makes  the  sitting  last  about  three  minutes.  The  current 
should  be  slowly  turned  off,  unless  spinogalvanization  is  to 
be  employed.  In  this  case,  the  anode  is  moved  slowly  down- 
ward to  the  end  of  the  spinal  cord  and  back  again,  consuming 
about  three  minutes,  and  the  current  is  slowly  turned  off. 
In  this  method  the  density  of  the  current  should  never  be 
greater  than  -^-^,  the  electrodes  should  be  held  in  firm  contact 
with  the  body,  the  duration  of  the  sitting  short,  the  applica- 
tions should  be  separated  by  several  days'  intervals,  and  great 
care  should  be  used  to  turn  the  current  on  and  off  slowly. 

In  the  treatment  of  neurasthenia  gastrica,  a  sitting  may 
be  given  daily,  and  the  sittings  should  be  diminished  in 
frequency  as  improvement  takes  place.  In  the  electric 
treatment    of    the    stomach    and    its   connected    ganglia,    we 


244  DISEASES  OF  TflE  STOMACH. 

are  decidedly  in  favor  of  small  doses  given  in  appropriate 
ways. 

In  myasthenia  gastrica  electricity  may  be  used  internally 
or  externally.  Internally,  either  faradism  or  galvanism  may 
be  employed.  The  stomach  must  be  clean  and  resting,  and 
about  one  pint  of  water  is  introduced  or  swallowed.  A  large 
plate  electrode  (200  sq.  cm.)  is  placed  over  the  epigastrium  and 
the  gastric  tube  electrode  is  introduced  and  connected  with 
the  negative  pole  and  a  current  of  from  five  to  ten  milliam- 
peres  is  turned  on.  The  external  electrode  may  be  moved 
during  the  sitting  to  the  left  and  over  the  dorsal  spine.  The 
current  is  slowly  turned  off.  Faradism,  however,  is  prefer- 
able to  galvanism,  the  external  electrode  being  smaller  (100 
sq.  cm.)  and  the  current  strong  enough  to  produce  painless 
muscular  contractions.  The  external  electrode  may  be  held 
still,  moved  or  stroked  over  the  stomach,  or  held  over  the 
beginning  of  the  dorsal  spine.  Intragastric  electrization  is 
rarely  practicable.  It  can  only  be  used  after  the  patient  has 
become  accustomed  to  the  tube,  and  this  rarely  happens 
except  in  conditions  demanding  frequent  lavage,  where  elec- 
tric treatment  is  often  useless.  The  possible  additional 
benefit  derived  from  it  is  outweighed  by  the  punishment 
inflicted ;  but  the  fatal  objection  is  that  the  method  is  uncon- 
trollable and  the  density  of  the  current  can  not  be  regulated. 

Another  method  of  internal  electrization  of  the  digestive 
tube  is  more  practicable,  and  may  be  often  used  in  myasthenia 
gastro-intestinalis  with  excellent  results.  This  is  recto- 
abdominal  galvanization.  The  rectal  electrode,  consisting  of 
a  short,  rather  stiff  tube,  is  so  arranged  that  the  mucous 
membrane  is  protected  against  direct  contact,  and  the  water 
can  be  introduced  through  it.  A  very  good  electrode  of  this 
sort  is  that  of  Rosenheim.  The  tube  is  introduced  and  half 
a  pint  of  warm  water  is  allowed  to  flow  in  and  to  fill  the 
rectum,  in  which  the  electrode  terminates.  To  this  is  at- 
tached the  positive  pole.  A  plate  electrode  of  100  sq.  cm.  is 
placed  over  the  epigastrium  and  connected  with  the  negative 
pole.  The  current  is  turned  on,  and  should  not  exceed  five 
milliamperes  (D  =  -j^-) ;  it  is  allowed  to  flow  continuously  for 
a  short  period  and  then  should  be  interrupted  a  number  of 
times.  The  external  electrode  is  allowed  to  rest  over  the 
solar  plexus  and  on  either  side  of  the  umbilicus  for  about 
one  minute.  The  whole  sitting  lasts  about  five  minutes.  A 
current  strength  of  three  milliamperes  is  generally  sufficient. 
An  application  may  be  made  every  four  or  five  days.  Before 
the  treatment  the  colon  should  be  thoroughly  emptied  by  a 


PHYSICAL    REMEDIES.  245 

saline  or  by  an  injection,  and  the  rectum  should  be  washed 
out  before  the  introduction  of  the  electrode. 

A  second  method  of  treating  myasthenia  gastrica  is  with 
the  faradic  current.  This  current  is  very  valuable  when  the 
abdominal  wall  is  flabby.  The  proper  external  application 
of  faradism  excites  secretion,  peristalsis,  and  absorption  and 
exercises  the  abdominal  muscles.  The  current  should  be 
strong  enough  to  produce  painless  contraction.  One  elec- 
trode of  100  sq.  cm.  is  held  to  the  left  of  the  dorsal  spine  and 
another  of  50  sq.  cm.  is  applied  over  the  epigastrium  and  the 
bellies  of  the  abdominal  muscles,  with  frequent  interruptions. 
The  sitting  should  last  about  ten  minutes  and  may  be  repeated 
daily. 

Adenasthenia  gastrica  without  an  anatomical  lesion  is  very 
rare,  but  it  may  be  met  with  as  a  result  of  shock  or  of  hys- 
teria. Spinogastric  galvanization  with  the  negative  pole 
over  the  stomach  may  be  beneficial,  and  should  be  combined 
with  general  galvanization  of  the  spine  or  with  general  faradi- 
zation. In  the  application  of  galvanism  to  the  spine,  the  posi- 
tive electrode  of  50  sq.  cm.  is  placed  over  the  back  of  the  neck 
and  the  negative  electrode  is  moved  from  the  upper  dorsal 
region  to  the  lower  end  of  the  cord.  Acurrent  strength  of  two 
milliamperes  ;  slow  increase  from  and  decrease  of  the  current 
to  zero  in  the  beginning  and  end  of  the  sitting,  which  should 
last  about  two  minutes  and  may  be  repeated  daily,  should  be 
recommended. 

2.  Electricity  in  Hypersthenia  Gastrica. — In  hypersthenia  gas- 
trica the  controlling  indication  is  sedation,  and  we  wish  to 
obtain  the  quieting  influence  of  electricity.  The  galvanic  is 
the  proper  current,  and  should  be  so  applied  as  to  get  the  pure 
polar  action  of  the  anode.  One  plate  electrode  of  lOO  sq.  cm.  is 
placed  over  the  upper  part  of  the  dorsal  spine,  and  is  connected 
with  the  negative  pole.  The  other,  of  the  same  size,  is  held 
firmly  over  the  stomach.  The  current  strength  shulod  not 
exceed  two  milliamperes,  and  the  current  must  be  very  slowly 
turned  on  and  off.  The  sittings  should  be  given  daily,  and 
should  last  five  or  ten  minutes.  This  method  of  using  elec- 
tricity often  gives  most  excellent  results,  and  is  employed  in 
gastrospasm,  in  spasm  of  the  orifices,  in  gastralgia,  in  habitual 
vomiting,  and  in  excessive  secretion,  when  not  excited  by 
irritant  contents  or  by  inflammation. 

3.  Electricity  in  Chronic  Gastritis. — In  chronic  gastritis  there 
may  be  either  a  state  of  irritation  or  of  depression,  according 
to  the  form  and  stage  of  the  process.  When  the  irritation  is 
the  expression  of  the  lesion  and  not  the  result  of  irritant  gas- 


246  DISEASES  OF  THE  STOMACH. 

trie  products,  the  sedative  pure  polar  influence  of  the  galvanic 
anode  is  very  valuable.  It  is  applied  in  the  manner  recom- 
mended in  the  treatment  of  hypersthenia  gastrica,  of  which 
this  is  the  inflammatory  form. 

If  depression  of  function  exist  and  the  process,  as  indicated 
by  the  functional  signs,  is  not  so  far  advanced  as  to  make 
•excitation  useless,  either  galvanism  with  both  large  plate 
electrodes  over  the  stomach  or  spinogastric  galvanization 
with  the  negative  pole  over  the  epigastrium  should  be  used. 
The  two  methods  are  described  under  the  electric  treatment 
of  neurasthenia  gastrica. 

The  faradic  brush  mildly  applied  on  the  dry  skin  increases 
cutaneous  sensibility  and  acts  on  deeper  parts  as  a  revulsive. 
It  may  be  used  to  modify  the  circulation  of  the  stomach.  A 
plate  electrode  is  held  over  an  indifferent  part,  and  the  brush, 
with  a  current  sufficiently  strong  to  excite  hyperemia  but  not 
much  pain,  is  applied  for  a  few  minutes  over  the  surface  be- 
tween the  left  sixth  and  tenth  ribs,  the  median  line,  and  the 
spinal  column. 

Electricity  is  a  valuable  remedy  in  the  treatment  of  the  dis- 
eases of  the  stomach  when  employed  in  a  definite  manner  for 
a  definite  purpose.  Its  use,  regardless  of  the  form,  strength, 
density,  polar  effect,  points,  and  duration  of  the  application, 
and  in  the  fond  hope  of  thus  accomplishing  something,  is  a 
waste  of  time. 

Massage. — The  physiological  action  of  exercise  differs  in 
important  particulars  from  that  of  massage,  the  first  being 
voluntary,  and  the  component  parts  of  the  body  furnishing 
the  source  of  power,  while  in  massage  the  patient  receives 
passively  and  is  under  the  influence  of  force  which  has  its 
origin  in  the  well-directed  efforts  of  another  person.  The 
voluntary  muscular  system  furnishes  about  45  per  cent,  of  the 
total  weight  of  the  body,  and  while  in  action  draws  to  it  the 
arterial  and  drives  out  the  venous  blood.  General  exercise, 
built  up  into  a  system  in  the  gymnasium,  is  a  powerful  revul- 
sive, and  draws  away  the  blood  from  the  internal  congested 
organs ;  but  it  uses  stored  force  and  fills  the  blood  with  waste 
products.  The  weak  may  not  be  able  to  stand  it,  and  it  puts 
additional  work  on  the  eliminating  organs.  It  excites  chiefly 
the  cerebrospinal  nerves. 

Abdominal  massage  uses  little  of  the  patient's  force,  forms 
little  waste  matter,  and  excites  chiefly  the  abdominal  sym- 
pathetic. It  forces  the  lymph  and  the  venous  blood  from 
the  abdominal  cavity  and  raises  arterial  pressure  by  filling  the 


PHYSICAL    REMEDIES.  247 

arteries  with  the  pressed-out  fluids.  It  consequently  purifies 
the  tissues  subjected  to  it. 

Abdominal  massage  is  decidedly  an  excitant  remedy,  and 
is  contraindicated  in  all  forms  of  gastric  hypersthenia,  of  acute 
inflammation,  of  ulcer,  of  morbid  sensibility,  and  of  chronic 
inflammation  associated  with  functional  excitation.  Massage 
can  only  cause  cancer  to  grow  and  to  spread  more  rapidly. 
It  should  never  be  performed  while  the  stomach  contains 
fermenting  food,  for  it  can  do  no  good  and  disorders  the 
intestines. 

A  great  deal  of  harm  can  easily  be  done  by  routine  abdomi- 
nal massage,  and  the  physician  must  prescribe  the  form  and 
employ  persons  with  special  training  to  give  it.  The  remedy 
may  be  used:  (i)  To  empty  the  stomach;  (2)  to  relieve  an 
associated  myasthenia  intestinalis ;  (3)  to  strengthen  the 
abdominal  wall ;  and  (4)  to  improve  the  abdominal  circula- 
tion. 

I.  To  empty  the  stomach  by  massage,  procedures  may  be 
used  which  act  reflexly  or  mechanically.  The  reflex-acting 
method  utilizes  the  connection  of  the  cutaneous  nerves  with 
the  abdominal  sympathetic,  the  gentle  excitation  of  4:he  skin 
being  transmitted  to  the  muscular  layer  of  the  digestive  tube. 
The  tip  of  the  thumb  rests  lightly  on  the  abdomen,  between 
the  symphysis  and  the  navel,  and  the  ends  of  the  fingers 
rapidly  circle  about  the  umbilicus.  No  pressure  is  exercised, 
the  tips  of  the  fingers  being  brought  in  mere  contact  with  the 
skin.  A  second  circle  maybe  made,  more  directly  and  exclu- 
sively over  the  stomach,  with  its  central  point  over  the  left 
costal  border  half  way  between  the  ensiform  process  and  the 
cartilage  of  the  ninth  left  rib.  Twelve  or  fifteen  circles  are 
made  about  each  central  point,  and  repeated  after  an  interval 
of  five  minutes.  The  procedure  is  very  useful  to  empty  the 
stomach  in  myasthenia  without  retention.  The  patient  soon 
learns  how  to  do  it  intelligently.  It  should  be  employed 
after  each  meal,  at  the  time  when  the  stomach  should 
normally  be  empty,  the  patient  lying  on  the  back  with  all 
clothing  loose. 

Reflex  excitation  of  peristalsis  may  also  be  employed  to 
strengthen  the  muscular  layer  in  myasthenic  retention.  The 
stomach  should  previously  be  emptied  by  lavage,  and  a 
glass  of  cold  water  should  be  administered. 

Zabludowski  has  recently  described  a  good  method  of 
emptying  the  stomach  mechanically.  The  mechanical  method 
is  used  in  the  treatment  of  myasthenia,  gastroptosis.  and 
obstructive  retention  where  the  gastric  muscle  is  insufficient 


248  DISEASES  OF  THE   STOMACH. 

and  quiet.  If  the  muscular  layer  is  hypertrophied,  tonic, 
and  powerful,  massage  can  do  no  good.  Tiiis  muscular  con- 
dition exists  where  there  is  obstructive  retention,  and  is  indi- 
cated by  the  increased  resistance,  by  the  higher  percussion 
note,  by  the  peristaltic  sounds,  and  by  the  absence  of  splashing. 
The  massage  is  intended  to  restore  muscular  compensation 
and  to  stretch  the  stricture  of  the  pylorus  due  to  non-malig- 
nant disease,  the  compressed  contents  acting  as  the  instrument 
of  dilatation.  Manifestly,  the  massage  expression  through 
the  pylorus  should  be  employed  only  in  special  conditions. 
The  stomach  should  be  thoroughly  washed  out  before  the 
evening  meal,  which  should  consist  of  food  in  a  state  of  fine 
subdivision.  Four  hours  later  massage  expression  may  be 
employed  and  the  stomach  left  retracted  under  the  influence 
of  circular  cutaneous  excitation. 

The  method  recommended  by  Zabludowski  follows  the 
direction  of  the  natural  peristalsis  from  the  fundus  to  the 
pylorus,  and  the  manipulations  are,  briefly,  as  follows: 

{a)  A  large  fold  of  the  abdominal  wall  and  stomach  is 
grasped  between  the  thumb  and  fingers  of  the  right  hand  as 
far  to  the  left  of  the  median  line  and  as  deep  as  possible ; 
the  contents  thus  caught  up  are  thrown  against  the  pylorus  ; 
this  manipulation  can  be  done  successfully  only  when  the 
abdominal  wall  is  thin  and  flabby.  The  method  of  Cseri  is 
better :  The  ulnar  border  of  the  left  hand  is  pressed  deep 
into  the  abdomen  along  the  greater  curvature  of  the  stomach 
as  it  runs  upward  toward  the  pylorus  ;  the  pyloric  end  of 
the  stomach  lies  in  the  palm  of  the  left  hand  ;  the  extended 
fingers  and  thumb  of  the  right  hand  sink  deep  into  the  body 
of  the  stomach  and  with  a  pushing  stroke  force  the  contents 
toward  the  pylorus. 

{b)  Where  the  abdominal  wall  is  thin  and  flabby,  the 
stomach  may  be  divided  into  two  cavities  by  the  fingers 
pressed  with  a  kneading  movement  deep  against  the  verte- 
bral column.  The  contents  of  the  p)'loric  division  are  pressed 
through  the  pylorus  by  moving  the  fingers  to  the  right  and 
upward,  dilating  the  orifice  like  a  bougie. 

{c)  The  finger-tips  of  both  hands  are  pushed  deep  into  the 
abdomen  along  the  left  costal  border  over  the  stomach  and 
the  oscillating  hands  knead  the  contents  toward  the  pylorus, 
while  the  fingers  are  kept  constantly  in  vibration.  This  pro- 
cedure is  a  powerful  excitant  of  peristalsis. 

{d)  The  stomach  is  grasped  like  the  uterus  in  the  placenta- 
expression  method  of  Crede,  and  the  contents  are  squeezed 
through  the  pylorus. 


PHYSICAL    REMEDIES.  249 

The  procedures  should  be  alternated.  The  massage  should 
never  be  painful  and  should  be  performed  only  while  the 
muscles  are  relaxed.  The  treatment  should  never  continue 
longer  than  ten  minutes,  the  patient  lying  half  the  time  on  the 
back,  and  the  other  five  minutes  on  the  right  side. 

2.  Myasthenia  intestinalis  is  often  associated  with  myas- 
thenia gastrica.  The  massage  of  the  stomach  should  then 
always  be  preceded  by  the  mechanical  emptying  of  the  colon. 
The  methods  described  by  Reibmayer  accomplish  this  object 
well.  If  the  contents  of  the  colon  are  fluid,  the  massage  may 
begin  with  the  cecum  ;  but  if,  as  is  commonly  the  case,  there 
are  solid  fecal  collections,  the  massage  should  begin  with 
the  descending  colon.     The  manipulations  are  the  following  : 

The  right  hand  is  laid  flat  over  the  descending  colon,  with 
the  fingers  outstretched  and  strengthened  by  the  finger-tips 
of  the  left  hand  over  the  metacarpo-phalangeal  joints.  The 
hand  is  moved  downward  and  inward,  avoiding  pressure 
against  the  iliac  bone,  the  fingers  following  the  dip  of  the 
sigmoid  flexure  into  the  pelvis. 

The  right  hand,  completely  extended,  is  next  placed  over 
the  cecum,  the  fingers  covering  the  umbilicus,  and  the  ulnar 
border  is  pressed  deeper  than  the  radial.  In  this  position, 
and  under  slight  pressure  of  the  balls  of  the  little  finger  and 
thumb  (the  other  fingers  remaining  passive),  the  hand  is 
moved  along  the  ascending  colon  to  the  right  costal  border, 
across  the  abdomen  in  the  course  of  the  transverse  colon, 
along  the  left  costal  border,  and  over  the  remaining  part  of 
the  colon.  Care  must  be  used  to  avoid  causing  pain  by  pres- 
sure against  the  bony  prominences. 

To  empty  the  cecum,  the  masseur  turns  his  left  side  to  the 
patient  and  places  the  right  hand,  with  distended  fingers 
directed  toward  the  symphysis  pubis,  over  the  right  iliac  fossa. 
The  fingers  are  strengthened  by  the  tips  of  the  fingers  of  the 
left  hand  applied  over  the  metacarpo-phalangeal  joints.  The 
movement,  with  gentle  pressure,  is  upward  over  the  cecum 
and  the  ascending  colon  until  the  fingers  reach  the  right  costal 
border,  and  then  inward,  gradually  relaxing  the  pressure  as  the 
fingers  pass  near  the  umbilicus,  to  the  starting-point. 

The  mechanical  emptying  is  completed  by  repeating  the 
massage  of  the  transverse  and  descending  colon,  and  peri- 
stalsis is  excited  by  the  reflex-acting  cutaneous  circles  around 
the  umbilicus.  Later,  as  the  case  improves,  the  solar  and 
splanchnic  plexuses  may  be  vibrated,  and  the  contents  of  the 
abdomen  rolled  between  the  vibrating  hands. 

3.  To  strengthen  the  abdominal  wall  the  massage  is  limited 


250  DISEASES  OF  THE  STOMACH. 

to  the  abdominal  muscles,  and  a  systematic  series  of  active, 
passive,  and  resisted  Swedish  movements,  aided  by  faradiza- 
tion, is  employed. 

Abdominal  Belts. — The  object  of  mechanical  treatment  by 
an  abdominal  belt  is  to  increase  abdominal  tension  and  to 
support  or  hold  in  replacement  the  dislocated  abdominal 
origans.  In  this  way  the  vagosympathetic  irritation  is  relieved 
and  the  disturbed  blood  and  lymph  circulations  are  restored. 

The  abdominal  viscera  are  hung  to  the  posterior  abdominal 
wall  and  to  the  diaphragm  above  the  plane  in  which  they  lie 
when  the  body  is  erect.  Consequently,  pressure  or  constric- 
tion at  a  higher  point  in  the  abdominal  cavity  than  their 
location  maintains  and  increases  the  downward  displacement. 
It  is,  therefore,  absolutely  essential  that  the  constrictions  above 
the  umbilicus  and  over  the  hypochondria  should  be  removed. 
The  stomach  must  be  able  to  make  room  for  itself  on  its  own 
level  as  it  becomes  more  and  more  distended  with  food,  and 
not  be  forced  to  make  room  for  itself  by  pressing  and  distend- 
ing downward.  No  mechanical  treatment  can  be  of  any  avail 
so  long  as  this  supra-umbilical  constriction  exists,  and  an  effort 
to  support  the  abdominal  organs  will  only  result  in  the  pro- 
duction of  excessive  abdominal  tension  and  in  the  compres- 
sion of  the  stomach. 

The  bandage  must  exert  a  proper  degree  of  pressure  from 
below  upward  and  backward  and  hold  the  organs  in  reposi- 
tion. The  support  should  be  very  firm  at  the  symphysis  and 
lose  itself  on  the  normal  level  of  the  transverse  colon. 

There  are  many  varieties  of  abdominal  belts  or  bandages. 
The  pelvic  belt  of  Glenard  is  simple  and  sustains  the  abdo- 
men. The  modification  of  Montuuis  is  more  suitable  for 
some  cases.  The  abdominal  corset  of  Landau  is  excellent  for 
increasing  abdominal  tension  and  for  supplying  an  artificial 
abdominal  wall.  The  bandages  of  Teufel,  of  Boas,  of  Rosen- 
heim, and  of  Bardenheuer  embody  useful  principles  and  often 
do  well  ;  but  it  is  best  to  have  the  bandage  made  to  measure 
so  as  to  fit  properly,  and  to  choose  the  form  which  best  meets 
the  mechanical  indications  of  the  particular  case. 

It  is  useless  to  apply  a  bandage  with  the  organs  in  uncor- 
rected displacement.  The  patient  should  assume  the  knee- 
chest  position  and  the  displacements  should  be  corrected. 
The  bandage  is  then  tightened  in  place.  If  the  organs  are 
very  movable, — floating, — they  must  first  and  always  be 
replaced  by  one  who  knows  how  to  do  it.  To  attempt  sup- 
port without  replacement  is  like  fitting  a  truss  on  an  unreduced 
hernia. 


S  }  MP  TO  MA  TIC    TREA  TMENT.  2  5  I 

The  bandage  of  support  should  be  fitted  on  in  the  morning 
while  the  stomach  is  empty,  and  may  be  removed  at  night, 
while  in  the  recumbent  position,  if  abdominal  tension  is  not 
very  low. 

The  belt  constitutes  an  artificial  abdominal  wall, and  should 
be  more  and  more  elastic  toward  the  upper  border.  The 
natural  abdominal  wall  should  be  strengthened  by  mas- 
sage and  electricity  and  by  very  gentle  active  movements. 
The  abdominal  belt  is  an  essential  part  of  the  treatment  of 
gastroptosis. 


CHAPTER   IV. 
SYMPTOMATIC  TREATMENT. 

The  object  of  the  symptomatic  treatment  is  the  relief  of 
the  manifestations  of  the  diseases  of  the  stomach  which  give 
the  patient  special  concern  or  discomfort.  The  most  impor- 
tant of  these  symptoms  which  require  relief  are  loss  of  ap- 
petite, pain,  vomiting,  and  flatulencj^. 

Loss  of  appetite,  where  there  is  no  anatomical  disease  of 
the  stomach,  is  often  relieved  by  orexin.  The  basic  orexin 
in  fine  powder  should  be  given  in  a  gelatin  capsule  in  a  single 
dose  of  from  three  to  five  grs.,  preferably  during  luncheon,  or, 
as  Penzoldt  recommends,  with  a  cup  of  bouillon  at  10  a.m. 
The  drug  should  not  be  continued  longer  than  a  week,  and 
should  never  be  given  when  there  is  an  anatomical  disease 
of  the  stomach  or  when  the  kidneys  are  not  healthy.  All 
medication  which  improves  digestion  increases  the  appetite, 
particularly  the  remedies  which  excite  secretion  and  arrest 
fermentation  or  putrefaction.  The  appetite  is  also  better 
when  nutritive  exchange  is  active,  and  proper  exercise  in  the 
open  air  is  one  of  the  best  means  of  increasing  it. 

Gastric  pain  may  often  be  best  relieved  by  the  removal  of 
its  proximate  cause.  Neutralization  or  combination  of  the 
excessive  hydrochloric  acid  may  give  relief,  or  the  removal 
from  the  stomach  of  its  irritating  contents  may  be  required. 
The  latter  is  the  only  proper  method  when  the  pain  is  due 
to  retention  and  fermentation.  Gastric  pain  is  often  neuralgic 
in  character.  Antipyrin  or  one  of  the  coal-tar  analgesics 
will  then  give  relief;  aconite  and  gelsemium  and  also  arsenic 
sometimes  act  well  in   the  obstinate  cases,  and  the  specific 


252  DISEASES  OF  THE  STOMACH. 

action  of  quiiiin  in  malarial  neural<^ia  should  be  remembered. 
The  quinin  is  best  given  combined  with  small  doses  of  mor- 
phin.  In  hyperesthesia  of  the  mucous  membrane,  nitrate  of 
silver  is  both  a  symptomatic  and  curative  remedy,  but  should 
be  given  only  when  the  stomach  is  empty.  Carbolic  acid  is 
a  good  temporary  substitute,  and  bromid  of  strontium  before 
meals  is  sometimes  beneficial.  The  pain  of  the  anatomical 
diseases  is  relieved  by  nothing  so  rapidly  and  completely  as 
by  morphin  administered  hypodermically.  Codein  is  less 
efficient,  but  possesses  some  advantages.  The  method  of 
administration  is  not  a  matter  of  indifference.  Morphin 
given  hypodermically  is  eliminated  by  the  mucous  membrane 
of  the  stomach,  and  about  one-half  of  the  injected  dose  can 
be  recovered  in  the  water  used  in  the  performance  of  lavage 
during  the  first  two  hours  after  the  injection.  The  long-con- 
tinued use  of  opiates  diminishes  the  secretion  of  both  the 
hydrochloric  acid  and  the  ferments,  and  leaves  the  mucous 
membrane  hyperesthetic.  A  full  dose  of  an  opiate,  however 
administered,  diminishes  secretion,  delays  the  digestive  trans- 
formation of  the  food  (particularly  starch),  and  decreases 
peristaltic  activity  and  the  tonicity  of  the  stomach  wall. 
The  functions  of  the  stomach  are  less  disturbed  by  codein 
than  by  any  of  the  other  anodyne  derivatives  of  opium,  and 
the  phosphate  of  codein  (by  mouth  or  hypodermically)  is 
the  best  preparation.  Belladonna  diminishes  starch  diges- 
tion and  prolongs  the  digestive  period,  but  it  controls 
excessive  gastric  secretion.  Coca  is  an  excellent  gastric 
sedative  when  the  pain  is  due  to  hyperesthesia  of  the  niucous 
membrane,  but  it  is  inferior  in  this  respect  to  nitrate  of  silver. 
A  good  preparation  of  cannabis  indica  is  sedative  and  does 
not  disturb  digestion.  Menthol  is  unreliable  and  we  have 
often  obtained  no  analgesic  action  from  resorcin.  The  follow- 
ing tablet  is  an  excellent  gastric  analgesic,  to  which  codein 
may  be  added  when  the  pain  is  spasmodic  or  very  severe  : 

R  .      Kxt.  belladonna.'  ale. , 

Ext.  cannaljis  indica.'  (Squibbs).     .    .  aa  .        .  gr.  y'j 
Ext.  cocx gr.  iij. 

In  the  treatment  of  all  forms  of  gastric  pain  except  that 
produced  by  a  local  irritant  in  the  stomach,  the  soothing 
effect  of  hot  external  applications  should  be  utilized.  The 
neuralgic  cases  are  sometimes  relieved  by  anodal  sedative 
galvanization. 

The  large  number  of  remedies  recommended  for  vomiting- 
is  good  evidence  of  their  inefficiency.     Revulsion  externally. 


PHYSIOLOGICAL    TREATMENT.  253 

ice  internally,  sips  of  champagne,  sips  of  hot  water,  cocain, 
carbolic  acid,  menthol,  oxalate  of  cerium,  small  doses  of 
ipecac,  and  sometimes  opiates  hypodermically  or  by  rectum — 
all  have  their  advocates.  It  is  better  to  modify  the  treatment 
according  to  the  cause.  When  due  to  gastric  irritation,  it  is 
well  to  give  large  drafts  of  tepid  water  to  wash  out  the 
stomach,  or,  when  possible,  use  lavage.  After  the  stomach  is 
thoroughly  emptied,  an  opiate  should  be  administered  hypo- 
dermically or  by  rectum.  The  vomiting  of  food  may  some- 
times be  controlled  by  applying  the  compress  of  Winternitz 
during  digestion,  or  by  the  introduction  of  the  food  through 
a  tube,  or  by  Merck's  resublimed  resorcin.  The  treatment  of 
this  troublesome  symptom  is  considered  in  the  special  part  of 
this  book,  and  most  of  the  remedies  likely  to  prove  of  value 
are  given  in  the  chapter  on  Habitual  Vomiting. 

The  treatment  of  gastric  flatulency  is  dependent  on  its 
cause.  The  gas  may  be  formed  by  fermentation,  or  by  decom- 
position of  carbonates  in  the  stomach,  or  may  be  swallowed 
with  the  food.  Gaseous  drinks  and  waters  containing  car- 
bonates should  be  excluded.  The  amount  of  air  swallowed 
with  the  food  produces  no  disturbance  unless  the  stomach 
is  myasthenic.  The  treatment  of  flatulency  thus  reduces 
itself  to  the  treatment  of  the  fermentation  or  of  the  myas- 
thenia. In  either  case,  a  glass  of  hot  water  will  often  enable 
the  stomach  to  expel  the  gas.  Abdominal  massage  will  also 
cause  the  relaxed  or  distended  stomach  to  contract  and  over- 
come the  expansibility  of  the  gas.  Strychnin,  however,  is 
the  sovereign  remedy  unless  fermentation  is  the  only  cause. 
Stimulants  and  nervines  of  various  sorts  are  advocated  with- 
out good  reason,  and  are  administered  with  but  little  benefit. 
This  chapter  will  be  ended  without  apology,  for  we  have  a 
feeling  akin  to  scorn  against  the  symptomatic  treatment  of 
diseases  of  the  stomach. 


CHAPTER  V. 

PHYSIOLOGICAL  TREATMENT. 

Physiological  treatment  is  based  on  the  functional  state  ot 
the  diseased  organ.  It  has  to  do  with  potency,  with  force  ; 
with  an  increase  or  decrease  of  vital  power ;  with  the  ab- 
normality displayed  by  the    cell  in  the    performance    of  its 


254  DISEASES  OF  THE  STOMACH. 

special  or  its  general  work.  Physiological  treatment  is 
directed  against  the  quantitative  or  qualitative  variation  in 
the  normal  activity  of  the  cell;  against  the  excessive  or  the 
insufficient  functional  activity. 

The  abnormal  functions,  therefore,  are  either  hypersthenic 
or  asthenic,  and  the  aim  of  medication  is  the  correction  of 
this  or  that  state.  A  third  possibility  is  the  combination  of 
the  two;  or,  rather,  lawless,  variable,  uncontrollable  activity. 
The  organ  no  longer  works  rhythmically.  With  the  stomach 
this  lawless  activity  is  clinically  a  dynamic  affection.  In  all 
cases  the  inconstant  expression  is  due  to  the  variable  local  ex- 
citation, and  can  not  be  considered  a  distinct  pathological 
type.  These  variable  conditions,  consequently,  do  not  demand 
special  consideration.  The  physiological  treatment  is  directed 
against  the  two  states — hyperstheniaand  asthenia.  The  treat- 
ment, then,  is  either  sedative  or  e.xcitant. 

Hypersthenia  Qastrica. — The  physiological  treatment  of 
this  functional  state  is  sedative,  and  is  determined  by  the  par- 
ticular factor  disordered, — sensation,  secretion,  motility, — by 
the  genesis  of  the  trouble,  and  by  its  dynamic  or  organic 
nature. 

The  indications  maybe  thus  enumerated:  (i)  Protection 
against  irritation;  (2)  diminution  of  functional  work;  (3) 
sedative  medication. 

I.  The  irritants  against  which  it  is  necessary  to  protect 
the  hypersthenic  stomach  may  be  introduced  with  the  food, 
or  they  may  be  formed  in  the  stomach,  or  they  may  be  pre- 
scribed as  remedies.  We  have  often  emphasized  the  princi- 
ple that  the  diet  must  be  selected  according  to  its  physiologi- 
cal action.  In  hypersthenia  the  diet  must  be  so  compounded 
as  to  be  as  indifferent  in  its  action  as  possible,  and  to  combine 
the  free  hydrochloric  acid. 

Another  source  of  gastric  irritation  is  the  accumulation 
of  digestive  products  and  secretions.  Peptones  e.xcite  free 
secretion,  but  the  most  excitant  of  digestive  products  are  the 
sugars.  Consequently,  the  accumulation  of  these  products 
in  myasthenia  and  in  diminution  of  absorption  should  be 
controlled.  Germ  products  are  even  more  irritating  than  the 
digestive  compounds.  The  protection  of  the  stomach  against 
irritation  requires  careful  selection  of  the  diet  and  of  the  drugs 
prescribed,  prevention  of  stagnation  and  retention,  and  control 
of  the  germ  growth. 

On  the  same  principle  which  requires  the  exclusion  of 
irritants  in  the  foods  and  drinks,  and  the  prevention  of  stag- 
nation and  fermentation,  all   irritant  drugs  must  be  avoided. 


PHYSIOLOGICAL    TREATMENT.  255 

The  neglect  of  this  precaution  often  leads  to  failure.  Medi- 
cine is  too  frequently  introduced  into  the  stomach  for  some 
particular  purpose,  it  may  be,  but  in  total  disregard  of  its 
local  action. 

2.  The  diminution  of  the  work  of  an  excited  organ  is  one 
of  the  fundamental  principles  of  therapeutics.  The  irritable 
stomach  deserves  all  the  partiality  that  can  be  shown  it.  This 
indication  may  be  met  by  an  indifferent  diet  of  mere  support, 
including,  in  the  severe  cases,  rectal  feeding  and  absolute  rest 
in  bed. 

3.  The  sedative  medication  may  be  internal  or  external. 
The  uses  of  water  and  electricity  have  already  been  discussed, 
but  a  few  drugs,  also,  are  valuable  gastric  sedatives.  Opium, 
coca,  bismuth,  aconite,  veratrum  viride,  belong  to  this  class. 
The  prolonged  use  of  the  alkaline  mineral  waters  in  large 
doses  is  often  beneficial,  but  the  most  reliable  gastric  seda- 
tive in  the  chronic  diseases  of  the  stomach  is  nitrate  of  silver. 

The  effect  of  the  nitrate  of  silver  is  most  manifest  when 
the  interior  of  the  stomach  is  douched  with  a  i  :  2000  or 
I  :  5000  solution.  In  the  morning,  when  the  stomach  is 
empty,  a  pint  of  the  solution  is  allowed  to  flow  in  through 
the  stomach  douche,  and  is  then  withdrawn  after  a  momentary 
delay.  To  secure  thorough  removal  the  stomach  may  be 
afterward  douched  with  plain  warm  water,  and  the  residue 
after  aspiration  may  be  expressed.  The  application  may  be 
made  once  or  twice  a  week  until  the  morbid  sensibility  and 
excessive  secretion  subside.  In  supersecretion  with  stagna- 
tion, the  douching  should  be  preceded  by  lavage.  The  use  of 
salt  as  a  chemical  antidote  after  the  douching  destroys  the 
sedative  action  of  the  silver.  The  nitrate  of  silver  may  be 
administered  by  the  mouth  in  solution,  but  is  much  less  effi- 
cient and  its  local  effect  is  accidental.  Very  little  is  likely  to 
escape  transformation  into  the  inert  chlorid  or  albuminate. 
Given  in  pill,  it  is  rendered  thus  inert  before  it  can  come  in 
contact  with  more  than  a  very  limited  part  of  the  mucous 
membrane.  The  stomach  douche  presents  the  most  efficient 
and  the  only  controllable  method  of  using  the  drug  as  a  local 
sedative. 

The  physiological  treatment  of  hypersthenia  gastrica  is  not 
the  same  in  all  its  forms.  When  the  excessive  activity  affects 
secretion  or  the  muscular  layer  in  a  constant  manner,  it  con- 
stitutes a  particular  dynamic  affection  or  it  is  a  sign  of  a  par- 
ticular anatomical  disease  of  the  stomach.  The  physiological 
treatment  constitutes  a  part  of  the  treatment  of  the  different 
diseases  and  will  be  discussed  in  detail  in  the  fourth  and  fifth 
sections. 


256  DISEASES  OE  THE  STOMACH. 

Asthenia  Qastrica. — The  physiological  treatment  of  asthenia 
gastrica  has  for  its  aim  the  restoration  of  the  depressed  func- 
tions ;  but  not  every  asthenic  state  is  to  be  treated  in  this 
way.  Tiie  restoration  must  be  proven  possible  before  it  is 
undertaken.  Where  disease  has  destroyed  the  noble  ele- 
ments such  treatment  would  be  useless.  Where  the  depres- 
sion is  the  result  of  active  inflammation,  excitation  would 
only  do  harm, 

A  very  valuable  remedy  in  asthenia  gastrica  is  the  stomach 
douche.  The  douche  should  be  given  in  the  morning  when 
the  stomach  is  empty,  the  funnel  being  raised  about  three 
feet  above  the  head  of  the  patient  so  as  to  get  a  forcible  rain 
douche.  Plain  water,  physiological  salt  solution,  or  carbonic- 
acid  water  may  be  used.  This  is  an  excellent  method  of 
exciting  the  functions  of  the  stomach  in  myasthenia,  in  aden- 
asthenia,  and  in  neurasthenia  gastrica.  The  stomach  should 
be  left  empty  and  quiet  for  half  an  hour  afterward. 

Food  is  one  of  the  most  powerful  physiological  remedies 
for  the  treatment  of  this  condition.  The  diet  is  so  selected  as 
to  exert  by  its  action  a  stimulating  effect  on  the  motor,  glan- 
dular, or  nervous  function.  Instead  of  favoring  the  stomach, 
we  push  it  on  to  its  highest  degree  of  capability. 

The  drugs  employed  in  the  physiological  treatment  of 
asthenia  are  commonly  known  as  tonics.  These  prepara- 
tions are  often  prescribed  indiscriminately,  with  a  view  to 
building  up  the  organism,  but  are  indicated  only  in  the  cura- 
ble states  of  depression,  where  a  little  excitation  would  do  no 
harm. 

The  simple  bitters  have  a  very  doubtful  effect  on  the  func- 
tions of  the  stomach.  Given  in  large  doses  in  health  for  a 
period  of  several  weeks,  they  sometimes  derange  digestion. 
Their  bad  effect  is  rarely  noticeable  with  small  doses.  The 
action  on  secretion  is  slight,  possibly  increasing  it  when  it  is 
normal  or  diminished.  The  motor  function  is  uninfluenced 
or  possibly  stimulated.  The  excitant  action  of  the  simple 
bitters  is  more  marked  when  they  are  combined  with  aro- 
matics.  The  three  most  useful  of  the  simple  bitters  are 
gentian,  columbo,  and  condurango.  Columbo  acts  more 
strongly  on  the  movements  of  the  intestines  than  do  the  other 
two,  but  all  diminish  the  decomposition  products  in  the  urine. 
Condurango  is  also  a  sedative  to  the  mucous  membrane. 
In  myasthenia  with  delayed  evolution  and  excessive  secre- 
tion, the  fresh  infusion,  combined  with  nux  vomica,  is  very 
valuable.  Clinically,  it  is  well  established  that  the  bitters 
sharpen  the  appetite  and  increase  the  secretion  of  saliva;  and 


PHYSIOLOGICAL    TREATMEN7\  2^7 

it  may  often  be  observed  that  under  their  influence  nutrition 
and  the  formed  elements  of  the  blood  improve.  The  bene- 
ficial effects  of  the  bitters  are  best  obtained  by  administration 
a  half  hour  before  meals.  It  is  probable  that  their  effect  is 
greater  on  the  stomach  after  they  are  out  of  it,  or  the  stomach 
is  left  by  them  in  a  state  more  susceptible  to  excitation. 
While  in  the  stomach  their  action  on  secretion,  according  to 
well-conducted  experiments,  is  no  greater  than  that  of  dis- 
tilled water. 

Strychnin,  on  account  of  its  more  pronounced  action,  is  of 
more  value  than  the  simple  bitters.  It  increases  muscular 
tone  and  excites  secretion.  Ipecac  in  very  small  doses  has  a 
similar  action  on  the  stomach,  and  the  wine  of  ipecac  may 
often  be  combined  advantageously  with  the  tincture  of  nux 
vomica  ;  but  when  full  doses  of  strychnin  are  desirable  it 
is  best  to  give  the  alkaloid  alone.  We  frequently  prescribe 
with  excellent  results  in  simple  myasthenia  and  in  adenas- 
thenia  gastrica  a  combination  of  these  remedies  in  tablet 
form  : 

R  .     Quininje, S^-  ^ 

Ipecac, • gr.  j-L 

Hydrastinin.  niuriat., 

Ext.  nucis  vomicae, aa gr.  ^V- 

All  hypersthenic  states  are  contraindications  to  the  employ- 
ment of  these  drugs.  Neither  should  they  be  prescribed  in 
the  anatomical  diseases  when  excitation  would  do  harm  or 
be  useless.  A  third  contraindication  is  often  overlooked.  In 
neurasthenia  gastrica  they  are  badly  borne,  and  in  pro- 
nounced myasthenia  they  may  convert  a  painless  into  a  pain- 
ful affection.  Anything  more  than  the  mildest  excitation  is 
often  injurious  in  myasthenia.  In  myasthenia  of  the  colon  a 
purgative  and  even  a  laxative  dose  of  cascara  will  often  leave 
an  enterospasm  which  may  continue  for  several  hours.  The 
descending  and  transverse  colon,  on  palpation,  may  be  then 
often  felt  as  hard  cords,  which  again  dilate  as  the  excessive 
irritation  ceases.  The  myasthenic  stomach  may  become  con- 
tracted under  the  same  influence  as  the  intestine.  Treatment 
which  makes  myasthenia  painful  is  too  stimulating,  and  the 
pain  is  the  revealing  sign  of  the  injury  being  done. 

Common  salt  and  the  bicarbonate  of  soda  may  be  made  to 
exert  a  very  beneficial  influence  on  the  depression  of  the 
functions  of  the  stomach.  The  bicarbonate  of  soda  only  acts 
as  an  excitant  of  secretion  when  given  in  very  small  doses 
before  meals;  five  grs.  in  a  wineglassful  of  water  half  an  hour 
17 


-'3< 


DISEASES  OF  THE  STOMACH. 


before  meals  is  sufficient.  The  salt  should  likewise  be  given 
in  very  small  doses  (three  grs.),  in  about  Y^  per  cent,  solution, 
on  an  empty  stomach.  The  small  quantity  of  the  weak 
solution  acts  after  several  days  as  a  very  energetic  excitant. 
Large  doses  or  strong  solutions  after  short  use  will  produce 
gastric  catarrh.  The  sodium  chlorid  also  stimulates  peri- 
stalsis. A  wineglassful  of  Saratoga  Kissingen  or  Vichy 
sometimes  give  very  satisfactory  results,  or  other  alkaline 
saline  waters  will  do  as  well. 


CHAPTER   VI. 
BACTERIOLOGICAL  TF^ATMENT. 

The  indications  furnishetl  by  the  bacteriological  signs  may 
be  variously  met  by:  (i)  Chemical  antisepsis;  (2)  removal 
and  exclusion  of  the  germs;  (3)  change  of  the  culture  soil 
and  removal  of  the  pathological  conditions  which  favor  germ 
growth. 

Chemical  antisepsis  is  with  some  practitioners  a  very 
popular  method  of  treating  gastric  fermentation,  but  it  is  the 
least  efficient  and  most  injurious.  The  fermentation,  not  being 
an  accident,  but  developing  in  consequence  of  the  existence 
of  favorable  conditions,  can  be  controlled  only  while  the  anti- 
fermentatives  are  present  in  the  stomach.  Antiseptics  are 
also  antipeptic,  and  irritate  the  mucous  membrane,  which  in 
fermentation  is  already  in  a  state  of  excitation.  This  method 
of  treatment  ordinarily  deserves  all  the  condemnation  which 
can  be  heaped  upon  it,  but  at  times  some  benefit  is  derived 
from  the  use  of  resubiimed  resorcin  (Merck),  of  salicin 
(Merck),  and  of  creosote. 

The  removal  of  the  germs  is  more  than  a  palliative  meas- 
ure, for  it  places  the  stomach  in  a  position  to  perform  its 
functions  unmolested.  For  the  safe  and  efficient  removal  of 
the  germs  there  is  no  method  comparable  to  stomach  wash- 
ing. As  a  remedy  against  excessive  fermentation  the  opera- 
tion should  be  thoroughly  done  according  to  the  rules  given 
in  the  chapter  on  Physical  Remedies.  Thus  the  continuity  of 
germ  development  is  rudely  broken,  and  leaves  comparatively 
few  germs  to  struggle  for  existence  on  a  much  decreased 
amount  of  food.     The  exclusion  of  germs  from  the  stomach 


CHEMICAL    TREATMENT.  259 

is  an  impossibility,  but  by  most  careful  cleansing  of  the  mouth 
and  throat,  and  by  selection  of  well-preserved  and  freshly- 
cooked  food,  much  can  be  done  to  diminish  the  number 
which  find  entrance.  The  mouth  should  always  be  made 
sweet  after  the  stomach  washing. 

A  very  valuable  method  of  controlling  fermentation  is  by 
sudden  and  complete  change  of  the  culture  soil.  The 
patient  is  placed  for  a  day  or  two  on  an  absolute  nitrogenous 
diet,  and  then  this  diet  is  suddenly  changed  for  one  consist- 
ing of  thoroughly  cooked  cereals,  and  again  changed  to  a 
proper  mixed  diet.  This  method  is  more  applicable  in  acute 
cases,  where  vomiting  has  partly  emptied  the  stomach,  a 
meat  and  &^^  diet  being  most  suitable  to  begin  with.  In  all 
cases  the  diet  should  be  composed  of  such  foods  as  are  least 
liable  to  undergo  the  form  of  fermentation  prevailing  in  the 
stomach. 

Chemical  antisepsis,  lavage,  and  diet  will  prove  only  pallia- 
tive if  no  change  has  been  produced  in  the  conditions  which 
permit  the  excessive  fermentation.  The  most  common  condi- 
tion is  motor  insufficiency,  and  the  promotion  of  the  churning 
and  evacuation  of  the  stomach  is  one  of  the  surest  methods 
of  keeping  it  clean.  The  fermentation  will  return  as  soon  as 
the  palliative  remedies  are  stopped,  provided  the  pathological 
conditions — such  as  motor  insufficiency  and  excessive  secre- 
tion— have  not  been  discovered  and  successfully  treated. 


CHAPTER  VII. 
CHEMICAL  TREATMENT. 

The  chemical  treatment  has  to  do  with  the  treatment  of 
special  symptoms  by  means  of  alkalies,  acids,  and  the  digestive 
ferments.  The  alkalies  are  employed  to  neutralize  the  exces- 
sive acidity  of  the  contents  of  the  stomach  during  digestion, 
while  hydrochloric  acid  and  the  digestive  ferments  are  very 
generally  prescribed  when  the  gastric  juice  is  deficient.  Con- 
sequently, chemical  treatment  maybe  required  in  hyperchylia 
and  in  hypochylia. 

Hyperchylia. — In  hyperchylia  the  chemical  treatment  is 
directed  against  the  excessive  hydrochloric  acidity,  which 
may  irritate  the  gastric  mucosa  and  may  disorder  intestinal 


26o  DISEASES  OF  TJJE   STOMACH. 

digestion.  The  excessive  hydrochloric  acidity  is  neutralized 
by  the  administration  of  alkalies  at  the  right  moment  an  din 
proper  doses. 

The  alkalies  have  for  a  long  time  been  employed  enijiiri- 
cally  in  the  treatment  of  the  diseases  of  the  stomach,  and  their 
universal  use  would  indicate  the  great  esteem  in  which  they 
are  held  by  the  profession.  Their  value  in  clinical  medicine 
is  due  to  their  physiological  action  on  secretion  and  on  nu- 
trition, more  than  to  their  properties  as  antacids.  As  antacids 
their  effect  is  temporary  and  without  permanent  benefit,  and 
unless  they  be  given  properly,  they  may  be  injurious. 

The  alkalies  most  in  vogue  are  the  sodium,  magnesium,  and 
calcium  salts.  The  choice  of  the  antacids  is  not  arbitrary  ; 
for  their  neutralizing  power  and  their  action  and  the  action 
of  their  chemical  products  on  secretion  and  on  the  bowels 
may  be  important.  Bicarbonate  of  soda  combines  less  than 
half  its  own  weight  of  HCl,  and  forms  common  salt  and 
carbonic  acid.  Calcined  magnesia  combines  nearly  twice  its 
weight  of  HCl,  and  forms  magnesium  chlorid.  Ammonio- 
magnesium  phosphate  combines  about  its  own  weight  of 
HCl,  and  forms  magnesium  and  ammonium  chlorids  and 
phosphoric  acid.  The  chlorids  of  soda  and  of  magnesium 
are  much  less  energetic  in  their  action  on  secretion  and  are 
much  less  irritating  than  are  the  chlorids  of  calcium  and  of 
ammonium.  From  the  ammonio-magnesium  phosphate  is 
liberated  phosphoric  acid,  which  is  nearly  as  strong  as  HCl. 
As  antacids  in  the  treatment  of  hyperchylia,  we  consequently 
prefer  magnesia  usta  and  bicarbonate  of  soda;  prescribing 
enough  of  the  magnesia  to  regulate  the  bowels,  and  correct- 
ing its  overaction  by  combining  bismuth  subnitrate  with  it. 
Only  enough  of  the  antacids  should  be  given  to  neutralize 
the  excess  of  HCl  and  to  control  the  pain  of  hyperchylia. 
The  small  doses  may  be  repeated  during  the  free  HCl  stage 
of  digestion,  but  it  is  rarely  advisable  to  attempt  to  neutralize 
the  gastric  contents  completely.  The  HCl  which  is  combined 
with  albiitiiin  should  not  be  neutralized. 

Hypochylia. — Hypochylia  is  very  common,  and  it  may  be 
beneficial  to  supply  the  deficiency  of  secretion  by  the  admin- 
istration of  hydrochloric  acid  and  pepsin  during  digestion. 
This  method  of  treatment  is  very  popular.  Physicians 
encourage  it,  it  seems  very  rational  to  the  laity,  and  drug- 
gists flood  the  market  with  digestive  mixtures.  We  assert 
with  emphasis  that  this  supplementary  chemical  treatment 
has  no  curative  value,  is  of  restricted  temporary  utility  in 
even  suitable  cases,  and  it  may  do  positive  harm. 


CHEMICAL    TREATMENT.  26 1 

Hydrochloric  acid  administered  during  the  period  of  gas- 
tric digestion  disappears  very  rapidly  from  the  stomach,  and 
it  should  always  be  given  in  combination  with  pepsin.  Both 
pepsin  and  hydrochloric  acid  are  necessary  for  the  peptoniza- 
tion of  albumin,  and  the  acid  and  ferment  are  administered 
proportionately,  or  nearly  so,  in  hypochylia. 

The  acid-pepsin  combination  should  be  given  only  when 
secretion  is  deficient  and  during  the  period  of  gastric  diges- 
tion. The  time  of  administration  and  the  dose  should  be 
regulated  by  the  functional  signs  and  by  the  quantity  and 
quality  of  the  diet.  The  greater  the  quantity  of  albumin  in 
the  meal,  the  larger  should  be  the  doses  and  the  sooner 
should  their  administration  begin.  If  the  meal  consists 
largely  of  non-nitrogenous  food,  the  smaller  should  be  the 
doses  and  the  later  they  should  be  given.  The  supply  thus 
meets  the  physiological  demand,  and  an  opportunity  is  given 
for  salivary  digestion. 

In  our  experience  the  best  results  are  obtained  by  repeated 
doses  during  the  period  of  gastric  digestion.  This  period 
has  no  fixed  length,  but  varies  with  the  character  of  the  meal. 
After  a  light  meal  that  remains  in  the  stomach  about  three 
hours  two  doses  will  usually  suffice — half  an  hour  and  an 
hour  after  eating.  After  the  chief  meal,  one  or  two  more 
doses  may  be  given,  an  hour  apart.  In  our  experience  it  is 
unnecessary  to  give  enough  pepsin  and  acid  to  completely 
digest  all  the  albumin  in  the  meal. 

The  supplementary  chemical  treatment  may  be  employed 
when  the  disease  of  the  mucosa  permits  a  certain  amount  of 
excitation.  When  the  mucous  membrane  should  be  given  rest 
and  protection,  the  administration  of  acid  and  pepsin  and  of 
predigested  foods  is  injurious.  The  supplementary  chemical 
treatment  may  be  used  when  the  work  of  the  intestines,  on 
the  efficiency  of  which  the  maintenance  of  the  balance  of 
nutrition  depends,  must  be  lightened;  but  acid  and  pepsin, 
and  the  vegetable  ferments  which  act  independently  of  the 
presence  of  free  hydrochloric  acid,  often  disorder  intestinal 
digestion  and  increase  intestinal  putrefaction. 


SECTION  IV. 
THE  DYNAMIC  AFFECTIONS  OF  THE  STOMACH. 

All  the  disorders  of  the  stomach  which  present  no  char- 
acteristic patholoi^ical  anatomy  are  classified  as  dynamic 
affections.  The  displaced  stomach  may  become  diseased,  or 
the  diseased  stomach  may  become  displaced,  and  it  matters 
not  whether  the  disease  of  the  stomach  be  anatomical  or 
dynamic.  It  may  be  thought  preferable,  when  a  displacement 
of  the  stomach  exists,  to  consider,  for  the  sake  of  simplicity, 
the  dynamic  affection  as  a  complication  or  as  an  accidental 
association.  In  like  manner  an  anatomical  disease  of  the 
stomach  may  coexist  with  a  dynamic  affection,  and  the 
anatomical  disease  may  develop  either  before  or  during  the 
course  of  the  dynamic  affection.  The  symptoms  are  then  the 
expression  of  the  dynamic  affection  combined  with  the  symp- 
toms and  signs  of  the  anatomical  lesion.  These  complex  cases 
should  receive  recognition,  and  they  are  not  rare,  for  disease 
often  defies  simplicity  and  exclusiveness.  The  dynamic 
affections  have  no  characteristic  pathological  anatomy,  but 
their  existence  is  neither  destroyed  nor  excluded  by  the  pres- 
ence of  anatomical  lesions  of  the  stomach.  The  anatomical 
lesions  may  coe.xist  with  the  dynamic  affection,  but  they  con- 
stitute a  separate  and  distinct  disease.  Some  of  the  dynamic 
affections  may  be  described  as  "  neuroses  of  the  stomach  "  ; 
some  of  them  are  "  functional  disorders";  but  the  dynamic 
affections  of  the  stomach  may  be  in  their  nature  neither  the 
one  nor  the  other. 

Practically,  this  is  one  of  the  most  important  sections  of  the 
pathology  of  the  stomach.  Here  disease  presents  itself  in  its 
genesis,  and  the  subsequent  evolution,  unless  arrested  by 
proper  treatment,  may  be  represented  by  an  inverted  pyramid. 
The  trouble  grows  along  deviating  lines,  and  becomes  more 
and  more  irresistible.  The  physiological  functions,  one  after 
the  other,  are  enlisted  with  the  forces  which  make  for  disease. 
The  disease  should  be  recognized  and  crushed  in  its  pre- 
anatomical  stage  if  permanent  damage  is  to  be  avoided.  This 
is  the  period  when  treatment  will  show  its  greatest  power  and 
give  the  most  brilliant  results. 

262 


THE  DYNAMIC  AFFECTIONS  OF   THE  STOMACH.        263 

A  general  characteristic  of  these  affections  is  the  speciahza- 
tion  of  the  unhealthy  variation.  The  disease  dissociates  the 
functions  of  the  stomach  and  affects  some  one  of  them  persis- 
tently and  in  a  particular  manner.  Now  it  is  a  disorder  of  secre- 
tion or  a  motor  trouble  ;  now  it  is  a  painful  increase  of  general 
sensibility  or  a  particular  sensation  of  the  stomach  which 
demands  attention.  Digestion  may  be  chemically  perfect  or 
the  stomach  may  churn  and  evacuate  its  contents  uncon- 
sciously, the  appetite  being  good.  One  function  is  persistently 
disordered ;  the  others  remain  intact.  The  affection  may 
be  paroxysmal  or  intermittent,  but  the  variation  from  the 
normal  always  recurs  in  a  particular  case  in  the  same  manner. 
In  the  course  of  the  disease,  however,  the  tendency  is  to 
spread  to  the  other  functions,  and  the  primary  dynamic  affec- 
tion may  be  supplanted  or  overshadowed  by  another.  The 
true  dynamic  affections  of  the  stomach  never  appear  "  like  a 
panorama  with  ever-changing  scenes."  Such  disorders  are 
symptoms  and  nothing  more.  To  consider  the  variable  gas- 
tric expression  of  a  disease  of  another  organ  as  a  distinct 
morbid  entity  is  manifestly  erroneous.  The  gastric  disturb- 
ances cease  when  the  exciting  disease  is  cured.  A  true 
dynamic  affection  is  capable  of  an  independent  existence,  be 
it  primary  or  be  it  secondary. 

The  manner  of  development  is  often  peculiar.  Suddenly 
beginning,  without  any  dietetic  error,  and  persisting  for  a  vari- 
able length  of  time,  the  end  may  be  no  less  sudden  ;  or  slow 
in  its  commencement,  progressing  by  leaps,  the  termination 
comes  when  least  expected.  The  unhealthy  variation  is  not, 
or  may  not  be,  persistent,  but  intermittent.  Rapid  changes 
for  better  or  for  worse,  without  a  perceptibly  adequate  cause, 
are  characteristic.  This  obscure  peculiarity  is  generally  a 
contribution  from  the  abdominal  sympathetic,  or  from  the 
brain,  or  from  the  general  but  temporary  state  of  the  body. 

The  dynamic  affections  may  be  in  no  close  relation  with 
the  digestive  act  or  with  the  alimentation.  The  symptoms 
may  exist  only  or  chiefly  during  the  digestive  period  in  some 
of  the  cases;  but  it  is  also  true  that  the  symptoms  may  occur 
when  the  stomach  is  empty.  Digestion  as  a  chemical  process 
may  be  perfect,  and  the  digestive  disorder  may  exist  only 
because  the  patient  suffers  and  complains  during  the  period 
of  functional  activity  of  the  stomach.  A  large,  a  small,  a 
mixed,  and  a  simple  meal  may  be  equally  well  or  badly 
digested.  The  physical  state  of  the  food  maybe  of  no  greater 
influence  than  in  health.  There  may  be  no  constant  relation 
between  alimentation  and  digestion  on  the  one  hand  and  the 


264  DISEASES  OF  THE  STOMACH. 

symptoms  on  the  other.  Nutrition  may  be  well  preserved, 
and  sometimes  even  in  spite  of  insufficient  alimentation, 
although  subnutrition  (pain,  vomiting,  starvation)  is  some- 
times as  marked  as  in  the  grave  anatomical  diseases  of  the 
stomach.  These  peculiarities  are  often  due  to  the  existence 
of  a  trouble  in  some  other  part  of  the  body  which  selects  the 
stomach  as  the  center  of  its  manifestation. 

The  dynamic  affections  of  the  stomach  develop  preferably 
in  a  particular  soil.  This  is  the  neurotic  or  nervous  tempera- 
ment or  constitution.  Some  persons  are  born  with  a  delicate 
and  overwrought  nervous  system,  and  others  acquire  it  by  the 
mode  of  life,  by  bad  habits,  and  by  too  exclusive  and  exces- 
sive mental  or  moral  development.  The  resulting  condition  is 
unstable  nervous  equilibrium — the  forerunner  often  of  the 
nervous  affections  of  the  stomach. 

Most  of  these  affections  are  more  frequent  in  women  than 
in  men,  the  proportion  being  about  one  to  ten  in  youth,  and 
gradually  changing  until  the  sexual  difference  becomes  much 
less  (about  one  to  two)  during  the  last  third  of  life.  The 
chief  exciting  causes  in  men  are  mental  overwork  and  the 
reverses  of  fortune.  The  dynamic  affections  are  common 
among  women  near  the  end  of  the  social  season  in  large  cities, 
but  are  infrequent  among  country  girls;  for  in  spite  of  the 
pure  air  and  sunshine  of  the  country  and  the  freedom  from 
the  withering  touch  of  "  culture,"  anxiety  and  sorrow  and 
disappointment,  and  disorders  of  menstruation,  of  reproduc- 
tion, and  of  lactation,  have  the  same  influence  in  the  hut  as 
in  the  palace.  The  predominance  in  women  may  be  explained 
in  part  by  their  mode  of  life,  their  delicate  organization,  and 
their  peculiar  diseases. 

The  marked  influence  of  the  mind  and  feelings  on  the  func- 
tions of  the  stomach  is  a  fact  long  established  by  observation. 
Physiology  and  anatomy  have  given  no  satisfactory  e.xplana- 
tion  of  this  intimate  relation  of  the  central  and  sympathetic 
systems;  but  the  recent  studies  of  Koiliker  and  others  have 
thrown  some  light  on  this  obscure  matter.  The  sympathetic 
is  a  richly  ringed  chain  of  unipolar  and  multipolar  cells  con- 
necting with  each  other  and  directly  and  indirectly  with  the 
central  cells  of  the  cerebrospinal  system.  The  units  of  both 
systems  have  psychic  and  somatic  functions.  As  regards 
the  central  nervous  system,  the  sympathetic  cells  are  of  two 
kinds — the  dependent  and  the  independent.  The  independent 
ganglionic  cells  are  chiefly  motor,  and  innervate  the  whole 
involuntary  muscular  system,  giving  tonicity,  producing  con- 
tractions of  the  muscular  fibers,  and  probably  regulating  also 


THE  DYNAMIC  AFFECTIONS  OF   THE  STOMACH.         265 

the  caliber  of  the  blood-vessels.  Some  of  these  cells  are  prob- 
ably sensory,  and  influence  secretion.  The  dependent  cells 
are  in  part  sensory,  and  convey,  particularly  in  disease,  the 
indistinct  visceral  impressions  to  consciousness ;  and  in  part 
are  motor,  and  enable  the  central  system  to  influence  indirectly, 
through  the  ganglia,  both  the  involuntary  muscles  and  the 
secreting  glands.  This  discloses,  in  brief,  the  anatomical  basis 
of  the  fact  long  known  to  the  clinician — the  influence  of  the 
mind  and  feelings  on  the  functions  of  the  stomach. 

In  many  of  the  dynamic  affections  of  the  stomach  the 
nervous  system  is  disturbed  out  of  all  proportion  to  the  local 
trouble,  and  insomnia,  disorders  of  sensation,  tachycardia, 
faintness,  dilatation  of  the  pupils,  hot  flushes,  and  blushing 
are  very  common.  In  health  the  organ  does  its  work  silently, 
but  when  the  sympathetic  is  irritable,  digestion  produces  an  in- 
definable discomfort,  and  distant  associated  disorders  develop. 
The  symptoms  are  not  characteristic,  and  they  may  be 
very  similar  in  the  anatomical  diseases  to  the  manifestations 
of  the  dynamic  affections.  In  the  one,  however,  is  the  con- 
stant and  controlling  and  palpable  anatomical  lesion,  and  in 
the  other  is  the  invisible  abnormality,  recognizable  only  by  its 
effects. 


CHAPTER  1. 
THE  SENSORY  DYNAMIC  AFFECTIONS. 

I.  BULIMIA. 

The  nervous  affection  of  the  stomach  characterized  by  a 
sudden,  imperative  desire  for  food,  and  occurring  in  par- 
oxysms and  more  frequently  than  in  health,  and  greater  than 
the  needs  of  nutrition,  is  known  as  bulimia  {^ouq  =  ox,  and 
Mfxaq  =  hunger).  Other  names  for  the  same  affection  are 
hyperorexia  {u-ip  =  excessive,  and  ope^iq  =  appetite)  and 
cynorexia  [x'jiov  =  dog,  and  opt^iq  =:  appetite). 

Etiology. — Bulimia  is  most  frequent  between  the  ages  of 
fifteen  and  forty,  and  in  the  female  sex.  It  occurs  as  a 
symptom  or  association  of  some  cases  of  ulcer,  of  functional 
adenohypersthenia,  of  hypersthenic  gastritis,  and,  very  rarely, 
of  carcinoma  and  of  obstructive  and  myasthenic  retention.  In 
mental  diseases,  and  in  organic  cerebral  troubles,  a  noteworthy 
percentage  of  the  cases  occur.  Hysteria  and  neurasthenia 
are  responsible  for  some  of  the  cases.  Disease  of  the  male 
and  female  sexual  organs  may  excite  the  affection.  Syphilo- 
graphers  report  some  cases  occurring  during  the  third  and 
sixth  months  of  syphilis.  Basedow's  disease,  intestinal  worms, 
pulmonary  tuberculosis  (first  and  second  stages),  and  preg- 
nancy are  found  among  the  causes.  Rupture  of  the  thoracic 
duct,  tuberculosis  of  the  mesenteric  glands,  menorrhagia, 
intestinal  fistula,  and  intestinal  hy^permotility  may  cause 
excessive  hunger;  but  it  is  not  evident  that  the  desire  for 
food  is  out  of  proportion  to  the  needs  of  nutrition.  Bulimia 
may  be  central,  reflex,  nutritive,  symptomatic,  and  idiopathic. 
As  an  unassociated  affection  of  the  stomach,  it  is  most  com- 
mon in  the  neuropath. 

Pathology. — The  pathology  of  the  affection  is  obscure. 
Irritation  of  the  encephalic  hunger-center  seems  a  plausible 
explanation  of  the  cases  due  to  diseases  of  the  brain  and  of 
nutrition.  Other  cases  appear  to  be  due  to  the  irritation 
of  the  nerve-endings  or  centers  of  the  vagosympathetic. 
Hunger  is  normally  excited  by  the  action  on  the  medullary 
hunger-center  of  the  changed  quality  or  quantitv  of  the  blood. 

266 


THE   SENSOR  Y  D  YNAMIC  AFFECTIONS.  267 

It  would  seem  that  bulimia  is  not  excited  in  this  manner,  for 
it  may  be  quelled  by  food  in  the  stomach  before  there  has 
been  time  for  its  absorption,  and  the  attacks  are  in  no  relation 
to  the  composition  of  the  blood  or  to  the  needs  of  nutrition; 
but  it  should  be  remembered  that  sensations  in  the  stomach 
may  inhibit  the  hunger-center  or  they  may  excite  it.  There 
is  nothing  against  the  supposition  that  either  peripheral  or 
central  causes  may  be  present  and  active.  Clinically,  there 
is  no  doubt  that  this  pathological,  excessive,  imperative 
hunger  is  expressed  by  sensations  located  in  the  stomach, 
and  it  may  be  accompanied  by  the  very  rapid  evacuation  of 
the  contents  of  the  stomach  into  the  duodenum. 

Clinical  Description. — In  the  mild  form,  a  sudden,  strong 
desire  for  food  may  occur  at  any  moment  during  the  day  or 
night,  while  the  stomach  is  full  and  active,  or  in  repose. 
There  is  a  little  discomfort  and  uneasiness,  possibly  a  little 
headache  or  vertigo,  a  slight  burning  or  gnawing  sensation  in 
the  stomach,  but  the  desire  for  food  is  not  imperative,  although 
it  is  exaggerated,  and  the  attack  passes  off  after  a  little  food 
or  drink  is  taken  into  the  stomach,  and,  after  intervals  of  very 
variable  length,  may  return  suddenly,  unexpectedly,  and 
inexplicably. 

The  severe  form  is  a  much  more  serious  affection.  The 
beginning  is  sudden,  inexplicable,  and  violent,  occurring  soon 
after  a  meal,  while  the  stomach  is  empty,  during  the  day  or 
night.  The  affection  may  be  continuous,  the  only  relief  being 
obtained  during  a  short  period  after  eating;  this  clinical  form 
may  be  accompanied  by  violent  exacerbations,  which  are 
most  frequent  in  the  forenoon. 

The  attacks  may  also  be  irregular  or  periodical,  and  the 
course  intermittent,  with  short  or  with  very  long  intervals. 
This  lawlessness,  or  absolute  disregard  for  all  rules,  is  a  dis- 
tinctive characteristic.  If  the  desire  is  not  satisfied,  the 
peculiar,  indefinable  visceral  sensations  become  more  and 
more  unbearable,  there  are  burning  and  pain  in  the  stomach, 
and  there  may  be  headache,  ringing  in  the  ears,  and  vertigo  ; 
or  the  face  may  become  pale,  the  extremities  cold,  and  the 
patient  may  faint.  The  desire  may  become  so  strong  as  to 
overpower  the  moral  sense,  and  food  be  taken  regardless  of 
its  quality  or  ownership  or  of  the  surroundings.  After  the  tak- 
ing of  food  the  sensations  subside,  but  the  effect  is  inde- 
pendent of  the  quantity,  the  quality,  and  the  nutritive  value 
of  the  food.  The  attacks  may  be  quelled  by  eating  a  little 
food,  or  very  large  quantities  may  be  required  to  still  the 
hunger.     But   often  the  bulimia  soon   returns,  imperative  in 


268  DISEASES  OF  THE   STOMACH. 

its  sti"enL;;th,  and  without  apparent  reason.  In  the  intervals 
between  the  attacks  tlie  appetite  may  be  normal,  or  the  severe 
attacks  may  be  followed  by  loss  of  appetite,  the  hun<jer-center 
beini^  apparently  exhausted  or  completeU'  inhibited. 

The  functions  of  the  stomach  may  be  normal  or  the  evacu- 
ation of  the  contents  may  be  too  rapid.  The  affection  is  fre- 
quently associated  with  excessive  hydrochloric  acidity,  but 
this  functional  adenohx-persthenia  may  alternate  with  normal 
secretioti.  At  least  one  important  functional  disturbing  influ- 
ence is  irregular  and  immoderate  eating.  The  course  of  the 
affection  is  variable,  and  it  may  terminate  in  spite  of  the  per- 
sistence of  the  causative  disease  or  condition.  It  is  rebellious 
when  due  to  encephalic  disease,  and  it  may  disappear  spon- 
taneously in  hysteria.  Bulimia  is  sometimes  the  cause  of 
myasthenia  gastrica.  of  gastritis,  and  of  intestinal  disease. 

Differential  Diagnosis. — Acoria,  polyphagia,  and  bulimia 
are  often  confounded.  In  acoria,  the  food  eaten  does  not  sat- 
isfy; the  patient  never  feels  that  he  has  enough,  while  the 
desire  for  food  may  be  normal  or  less  than  normal.  In  pol)'- 
phagia  there  is  a  good  appetite  associated  with  a  delayed 
feeling  of  satisfaction;  or,  at  least,  the  sensation  of  having 
eaten  enough  does  not  become  so  strong  as  to  interfere  with 
the  enjoyment  of  eating  more — this  is  common  gluttony. 
In  bulimia  there  is  strong,  imperative,  often  unbearable 
hunger,  which  may  be  satisfied.  From  the  form  of  gastralgia 
which  occurs  only  when  the  stomach  is  empty  it  is  distin- 
guished by  the  strong  and  imperative  appetite  which  accom- 
panies the  pain,  and  by  the  occurrence  of  some  of  the  attacks 
when  the  stomach  still  contains  food. 

Treatment. — The  etiological  treatment  is  no  less  essential 
in  bulimia  than  in  the  other  nervous  affections  of  the  stom- 
ach. The  hysteria  or  neurasthenia  may  demand  a  combined 
systematic  cure,  consisting  of  isolation,  rest,  diet,  massage, 
electricity,  hydrotherapy,  and  suggestive  moral  control.  The 
other  causative  diseases  require  particular  medication,  a  mere 
outline  of  which  would  here  be  out  of  place. 

Antipyrin,  or  a  similar  analgesic,  may  moderate  the  sever- 
ity of  the  attack.  Opium  or  codein  may  also  be  used.  Both 
of  these  drugs  are  valuable  in  the  diabetic  form.  The  bromids 
of  strontium  and  arsenic  are  palliative,  and  sometimes  rapidly 
curative,  remedies.  Fifteen  grs.  of  the  strontium  salt  may  be 
given  three  or  four  times  a  day,  half  an  hour  before  eating,  or 
tablets  of  the  arseniate  of  soda  (Jjj-  of  a  gr.)  should  be  given 
during  the  period  of  gastric  activity.     We  have  obtained  the 


THE   SENSORY  DYNAMIC  AFFECTIONS.  269 

best  results  from  a  combination  of  codein,  extract  of  coca,  and 
extract  of  hyoscyamus. 

The  intragastric  douche  may  be  of  some  service,  and  several 
glasses  of  hot  water,  given  in  the  same  manner  as  in  the  treat- 
ment of  chronic  gastritis,  are  sometimes  beneficial. 

The  diet  is  determined  in  part  by  the  associated  disease,  and 
should  be  sufficient  to  supply  the  needs  of  nutrition.  Milk, 
finely-divided  cereals,  lean  fish,  the  soft  part  of  small,  fresh 
oysters,  the  least  excitant  meats,  dry  toast,  indifferently  acting 
vegetables,  etc.,  may  be  combined,  and  ordered  in  small  and 
frequent  meals.  Sweets  should  be  excluded,  but  enough  fresh 
butter  (unsalted)  should  be  ordered  to  furnish  the  needed 
quantity  of  fat.  The  patient  should  live  and  exercise  in  the 
open  air,  and  whenever  subnutrition  exists  a  very  nourishing 
diet  is  absolutely  essential. 


11.  ACORIA. 

Acoria  (a,  privative,  and  -/.opiw^vin,  I  have  enough  ;  or  y.6jt<iq, 
satiety)  is  a  rare  nervous  affection  of  the  stomach,  characterized 
by  loss  of  the  special  sensation  of  satiety.  The  patient  never 
feels  that  he  has  eaten  enough,  whether  the  meal  be  small  or 
very  large.  The  appetite  is  no  sharper  than  in  health,  indeed, 
it  is  often  diminished,  and  the  proper  quantity  of  food  to  be 
eaten  in  order  to  avoid  overloading  the  stomach  must  be  esti- 
mated by  reasoning. 

Nature  and  Causation. — Some  authors  claim  that  the  affec- 
tion is  a  peripheral  anesthesia,  while  others,  whose  views  are 
upheld  by  autopsies,  have  found  the  trouble  to  be  due  to 
compression  of  the  pneumogastrics  and  to  softening  of  the 
nuclei  of  origin  of  their  posterior  roots.  Acoria  may  be 
encountered  in  diabetes,  but  the  large  majority  of  cases  occur 
in  the  neuropath,  particularly  after  shock  and  depressing 
emotions  (neurasthenia  and  hysteria).  It  may  be  produced 
by  the  crushing  influence  of  a  great  sorrow.  Acoria  is  an 
asthenic  affection,  and  it  is  never  associated  with  bulimia. 

The  sensation  of  satiety  is  not  a  mere  negative  sensation, 
as  some  contend,  signifying  the  entrance  of  the  hunger-center 
into  a  state  of  repose  Acoria  may  coexist  with  anorexia. 
Neither  is  acoria  a  mere  continuance  of  the  hunger-center  in 
a  state  of  excitation,  for  the  desire  for  food  may,  in  this  affec- 
tion, disappear  during  the  course  of  a  meal  in  spite  of  the  fact 
that  the  patient  does  not  feel  that  he  has  had  enough.  Some 
of  the  patients  with  acoria  have  no  sensation  of  fullness  and 


2/0  DISEASES  OF  THE  STOMACH. 

weight  from  overloading  the  stomach  with  food  or  from 
strongly  inflating  it  with  air,  but  others  complain  of  pain  as 
well  as  fullness  and  heaviness  in  the  abdomen.  In  one  of 
our  cases  we  were  able  to  locate  these  latter  sensations  in  the 
colon.  It  seems  probable  that  the  sensation  of  satiety  is 
identical  with  a  particular  state  of  the  gastric  "  muscular 
sense,"  and  may  be  intensified  by  certain  associated  sensations, 
as  weight,  fullness,  discomfort,  and  cessation  of  the  appetite. 
Acoria,  in  keeping  with  this  view,  is  a  special  gastric  anesthe- 
sia, which  may  be  central  or  peripheral  in  origin. 

Diagnosis. — The  diagnosis  consists  in  the  detection  of  the 
symptom,  and,  when  possible,  also  of  its  cause,  the  etiology 
serving  as  a  guiding  thread  in  the  search.  The  only  mani- 
festation of  acoria  is  the  loss  of  the  sensation  of  satiety,  and 
the  patient  is  exposed  to  myasthenia  and  gastritis  from  over- 
eating. 

Treatment. — The  treatment  of  acoria  consists  chiefly  in 
moral  management,  hygiene,  and  excitant  hydrotherapy.  The 
intragastric  cold  douche  may  be  tried,  and  the  hot  or  cold 
needle-bath  should  be  used  to  tone  the  nervous  system.  Gal- 
vanization of  the  vagosympathetic,  the  cathode  over  the 
stomach,  and  the  anode  moved  over  the  cervical  centers,  in 
the  manner  described  in  the  chapter  on  electric  treatment, 
should  be  tried.  Less  active  are  intragastric  and  epigastric 
electrization.  Strychnin  is  valuable,  and  it  should  be  given 
in  increasing  doses  to  the  full  physiological  effect,  and  then 
continued  for  some  time  in  ordinary  doses.  Frequent  and 
small  meals  should  be  given,  for  the  anesthesia  is  not  likely 
to  be  relieved  by  overdistending  the  stomach.  The  treatment 
must  also  be  causative,  and  a  systematic  cure  may  be  required 
by  the  neurasthenia  or  by  the  hysteria  which  so  frequently 
accompanies  acoria. 


ill.  PAROREXIA. 

Parorexia  {7raf)d,  aside,  and  of^e^ie;,  appetite)  is  a  nervous  per- 
version of  the  appetite.  Bulimia,  anorexia,  and  acoria  are 
quantitative  variations  of  the  special  sensations  of  the 
stomach  ;  but  parorexia  is  qualitative. 

The  appetite  may  be  selective,  and  there  may  be  a  craving 
for  special  articles  of  the  ordinary  diet — pickles,  sweets,  ices, 
spices,  condiments  (malacia).  This  common  perversion  hardly 
deserves  consideration  in  itself,  unless  accompanied  by  ex- 
clusion of  the  more  nutritive  foods;  but  it  may  play  an  im- 


THE    SENSORY  DYNAMIC  AFFECTIONS.  2'J  I 

portant  part  in  the  etiology  of  the  diseases  of  the  stomach. 
The  appetite  may  be  more  seriously  perverted,  and  non- 
alimentary,  injurious,  even  disgusting  articles  may  be  eaten 
(pica).  This  form  is  common  among  the  little  plantation 
negroes  of  the  South, — the  so-called  "  dirt-eaters," — and 
seems  to  be  more  prevalent  in  the  spring  and  in  malarial 
regions.  It  may  be  associated  with  bulimia,  and  the  immediate 
prevention  of  the  pernicious  habit  may  cause  great  suffering, 
which  is  relieved  by  the  administration  of  food.  It  is  a  popular 
belief  that  "dirt-eating"  is  a  sign  of  intestinal  worms,  and 
the  association  often  exists.  The  habit  may  seriously  affect 
digestion  and  nutrition,  and  is  a  cause  of  gastro-enteritis. 

Parorexia  is  most  common  in  the  chlorotic  or  neurotic 
girl,  particularly  during  the  menstrual  period.  It  frequently 
accompanies  pregnancy,  and  may  be  caused  by  sexual 
excesses. 

The  insane  and  the  hysteric  may  swallow  all  sorts  of 
things — pins,  needles,  urine,  feces  ;  but  this  is  a  disease  of 
the  mind,  and  not  a  perversion  of  the  appetite. 

Treatment. — It  is  difficult  to  formulate  a  general  treatment 
of  parorexia.  It  is  an  irritative  affection,  and  sedation  is  the 
controlling  indication,  which  should  be  combined  with  good 
digestive  hygiene  and  with  the  management  of  the  associated 
condition.  The  stomach  of  the  "dirt-eater"  should  be 
thoroughly  washed  out,  and  the  complicating  excessive 
secretion,  bulimia,  hypersthenic  gastritis,  malaria,  intestinal 
worms,  enteritis,  anemia,  or  inanition  should  be  given  proper 
attention. 


IV.  ANOREXIA  NERVOSA. 

Complete  loss  of  appetite  may  be  a  symptom  of  a  large 
number  of  diseases,  and  does  not  constitute  anorexia  nervosa, 
which  is  a  very  serious  nervous  affection  of  the  stomach. 
The  appetite  in  this  disease  may  be  completely  lost,  but  the 
loss  is  associated  with  a  systematic  refusal  to  take  food  for  a 
particular  reason  or  motive.  The  mind  is  up  in  arms,  and 
with  rare  composure  excludes  all  but  a  little  food,  and  seems 
satisfied  with'  the  result.  The  loss  of  appetite  is  the  "only 
gastric  symptom.  The  other  symptoms  are  mental  and  those 
that  result  from  the  voluntary  starvation. 

Etiology. — Anorexia  nervosa  is  a  disease  of  the  adult  neu- 
ropath, but  it  may  also  develop  in  persons  who  are  neither 
neurotic   nor   nervous.     It   is   most   frequent  between  fifteen 


2/2  DISEASES  OF  THE  STOMACH. 

and  twenty,  and  cases  are  very  rare  before  this  age  and 
after  thirty.  Most  commonly  met  with  in  young  girls; 
it  may  also  occur  in  young  men.  It  is  almost  unknown 
in  the  active,  outdoor-living  country  girl,  and  develops  more 
frequently  in  the  nervous,  delicately  constituted  girl  who  is 
brought  under  the  withering  influences  of  enforced  culture 
and  imprisoned  inactivity.  It  is  sometimes,  but  rarely,  en- 
grafted on  a  painful  affection  of  the  stomach,  and  is  frequently 
associated  with  displacements  of  the  abdominal  viscera ;  but 
no  causal  relation  of  this  kind  can  be  established,  and  the 
association  is  accidental,  the  deforming  effects  of  the  corset 
being  very  common. 

The  insane  sometimes  persistently  refuse  to  take  food ; 
and  hysteria  seems  able  to  mimic  everything,  and  includes 
anorexia.     This  is  the  symptomatic  form. 

The  primary  form  has  been  attributed  to  anesthesia,  or  to 
perversion  of  the  sensibility  of  the  gastric  nerves  (Fenwick), 
which  prevents  the  starving  tissues  from  giving  expression  to 
their  need  of  nutriment.  This  theory  is  plausible,  and  the 
condition  seems  almost  essential  to  the  successful  and  com- 
placent carrying  out  in  practice  of  the  steadfast  and  wilful 
refusal  to  take  sufficient  nourishment. 

The  adoption  of  a  very  insufficient  diet  maybe  self-imposed 
for  a  variety  of  reasons.  The  developing  distaste  for  food  is 
encouraged,  and  one  article  after  another  is  excluded  "  because 
I  do  not  like  it,"  or  "  because  this  food  increases  my  discom- 
fort, and  it  is  useless  and  harmful  to  eat  what  you  can  not 
digest."  In  some  cases  the  conduct  resembles  closely  hys- 
terical posing,  and  is  a  plea  for  sympathy  and  for  attention. 
The  solicitude  of  family  and  friends  only  encourages  the  patient 
to  persist  in  the  voluntary  starvation.  Shock,  grief,  great 
sorrow,  disappointment  in  love,  and  all  causes  of  moral  depres- 
sion may  mark  the  beginning  of  the  disease.  In  many  cases 
there  is  no  explanation  of  the  affection  to  be  found  in  the 
habits,  the  circumstances,  or  the  surroundings. 

Clinical  Description. — The  clinical  history  of  anorexia  ner- 
vosa is  that  of  slow,  progressive  inanition  occurring  under 
peculiar  circumstances.  In  the  beginning,  digestive  power  is 
normal,  and  the  insufficient  diet  is  not  enforced  by  a  digestive 
disease  but  is  adopted  and  maintained  for  certain  motives  or 
reasons  known  to  the  patient. 

In  the  early  stage,  for  a  short  while,  the  weight  and  the 
strength  may  be  preserved.  Great  activity  is  sometimes 
shown  by  patients  in  order  to  prove  the  correctness  of  their 
conduct,  and  they  often  show  a  peculiar  nervous  restlessness. 


THE   SENSORY  DYNAMIC  AFFECTIONS.  273 

The  loss  of  color  and  the  appearance  of  ill  health  may  be 
hardly  noticeable.  This  stage  lasts  longer  in  hysteria,  of 
which  the  anorexia  nervosa  may  be  monosymptomatic,  and 
seems  to  bemade  possible  by  the  diminished  nutritive  activity, 
which  is  common  enough  in  hysteria. 

The  inanition  progresses  and  becomes  more  evident — in 
diminution  of  strength  and  weight,  in  the  slow  pulse,  the  cold 
extremities,  constipation,  scant  and  cloudy  urine.  The  sleep 
is  restless,  disturbed  by  dreams,  and  there  is  commonly  in- 
somnia. The  ankles  may  swell,  the  patient  grows  weaker, 
and  excessive  activity  produces  exhaustion.  The  family  and 
friends  become  alarmed  ;  but  the  patient,  irritable  and  moody, 
is  satisfied,  and  makes  no  effort  to  take  more  food,  which,  if 
forcibly  or  authoritatively  given,  may  be  rejected  by  vomiting. 

If  the  slow  inanition  is  not  arrested,  the  condition  becomes 
more  and  more  serious.  Pale,  emaciated,  weak,  haggard,  the 
patient  stands  on  the  verge  of  exhaustion,  which  is  the  second 
stage.  The  temperature  is  usually  subnormal,  but  may  be 
normal,  or  there  may  be  at  times  slight  fever.  Inanition- 
delirium,  with  hallucinations,  develops.  All  food  may  be 
refused.  The  digestive  power  is  correspondingly  depressed 
and  the  stomach  may  be  intolerant.  Constipation  is  obstinate, 
and  the  hard,  lumpy  stool  consists  of  the  secretions  of  the 
digestive  tube.  There  may  be  periodical  diarrhea,  accom- 
panied by  the  discharge  of  false  membrane.  The  abdomen  is 
sunken  and  the  anterior  abdominal  wall  is  nearly  in  contact 
with  the  vertebral  column  when  the  patient  lies  on  the  back. 
The  skin  is  rough,  dry,  and  hangs  like  a  bag  around  the  flabby 
muscles  and  the  prominent  bones.  The  features  are  wasted, 
and  the  sunken  eyes,  with  dilated  pupils,  are  surrounded 
with  dark  rings.  Bedsores  develop,  and  the  exhaustion  may 
end  in  collapse,  rapid  fall  of  temperature,  and  death  ;  or  a 
fatal  termination  may  occur  earlier  through  pneumonia  or 
some  other  complicating  affection,  the  half-starved  body  fall- 
ing an  easy  prey  to  bacterial  invasion. 

The  urine  diminishes  in  quantity,  and  in  the  stage  of  exhaus- 
tion is  very  scant,  and  only  four  to  six  gm.  of  urea  are  passed 
in  the  twenty-four  hours.     Albuminuria  is  exceedingly  rare. 

The  blood  is  that  characteristic  of  simple  inanition.  The 
percentage  of  red  cells  divided  by  the  percentage  of  hemo- 
globin is  equal  to  one  The  fresh  specimen  of  the  blood 
examined  with  the  microscope  may  be  much  better  than  the 
appearance  of  the  patient  would  lead  one  to  expect.  The 
number  of  red  corpuscles  in  the  cubic  millimeter  may  be 
nearly  normal,  the  volume  of  the  blood  being  probably 
18 


274  DISEASES  OF  THE  STOMACH. 

diminished,  and  this  vital  fluid  suffers  only  after  most  of  the 
stored  fat  and  muscles  have  been  eaten  away.  The  number 
of  white  corpuscles  in  the  cubic  millimeter  of  blood  is  very 
small,  fallinf^  as  low  as  2000. 

Diagnosis. — A  complete  loss  of  appetite,  the  absence  of 
any  serious  organic  disease,  the  mental  condition,  the  charac- 
teristic genesis  and  evolution,  the  slow  progressive  inanition 
due  to  an  insufficient  diet, — leave  those  who  have  seen  the 
disease  in  little  doubt  as  to  its  nature. 

Differential  Diagnosis. — A  large  number  of  diseases  are 
accompanied  by  loss  of  appetite  and  by  emaciation.  The 
appetite  is  diminished  or  lost  in  most  of  the  febrile  diseases. 
Diseases  of  the  blood,  cachectic  conditions,  severe  intestinal 
diseases,  the  painful  diseases  of  the  abdomen,  chronic  malaria, 
and  some  cases  of  tuberculosis,  are  accompanied  by  loss  of 
appetite.  Opium,  alcohol,  tobacco,  digitalis,  and  many  other 
drugs,  when  used  for  a  long  time,  destroy  the  appetite. 
Chronic  asthenic  gastritis,  gastric  retention  and  carcinoma 
are  usually  accompanied  by  loss  of  appetite ;  but  in  all 
these  diseases  the  patients  are  alarmed  at  their  condition, 
and  are  willing  to  eat,  and  do  all  in  their  power  to  get  well. 
The  causative  disease  will  be  discovered  on  examination. 
When  the  loss  of  appetite  is  symptomatic,  symptoms  are 
present  which  do  not  belong  to  the  symptom-group  of  ano- 
rexia nervosa,  the  blood  and  urine  changes  of  which  may 
also  be  valuable  differential  signs.  In  the  early  stage,  the 
gastric  functions  will  be  found  normal,  and  even  in  the  stage 
of  exhaustion  the  digestive  power  may  be  good.  There  are 
no  functional  signs  of  an  organic  or  functional  disease  of  the 
stomach. 

Tubercular  meningitis  and  tubercular  peritonitis  may  be 
difficult  to  exclude.  The  somnolence,  and  the  delirium  in 
the  advanced  stage,  if  the  patient  be  then  seen  for  the  first 
time,  and  the  progressive  character  of  the  trouble,  may  well 
excite  suspicion.  But  other  signs  of  these  diseases  may  be 
present,  and  the  wilful  and  dogged  refusal  of  food,  in  spite  of 
the  integrity  of  gastric  digestion,  is  characteristic  of  anorexia 
nervosa. 

Treatment. — The  indications  in  the  management  of  a  case 
of  anorexia  nervosa  are:  (i)  To  restore  the  balance  of  nutri- 
tion ;  (2)  to  treat  the  gross  symptoms ;  (3)  to  improve  the 
mental  and  nervous  condition. 

In  the  early  stage  it  is  difficult  to  secure  the  co-operation 
of  the  family  and  friends,  who  often  fail  to  see  the  necessity 
of  firm   and  absolute  control  of  the  patient.     The   digestive 


THE   SENSORY  DYNAMIC  AFFECTIONS.  2/5 

power  is  still  good,  and  in  order  to  meet  the  first  indication  it 
is  only  necessary  that  a  sufficient  quantity  of  food  be  given. 
To  do  this,  while  surrounded  by  the  family  and  friends,  may 
tax  all  the  resources  of  the  physician. 

It  is  unnecessary  to  prescribe  a  restrictive  or  exclusive  diet. 
The  articles  may  be  selected  from  the  diet  of  health,  and  the 
taste  of  the  patient  should  be  taken  into  consideration.  But 
the  physician  who  accepts  suggestions  runs  the  risk  of  losing 
his  authority,  and  without  moral  control  his  efforts  will  prove 
useless.  A  bitter  tonic  may  be  given, — strychnin,  quinin, 
columbo,  etc., — but  this  alone  will  do  little  good.  Fowler's 
solution  combined  with  an  aromatic  bitter  may  be  tried;  or 
the  interior  of  the  stomach  may  be  douched  with  a  ^  per  cent, 
salt  solution  or  with  a  bitter  infusion  (Kussmaul,  Fleiner). 
Penzoldt  recommends  orexinum  basicum  (four  grs.  in  a  cap- 
sule or  wafer  at  ii  a.m.,  with  a  cup  of  bouillon).  The  con- 
stipation will  disappear  with  the  increased  amount  of  food ; 
and  warm  clothing,  moderate  exercise,  hydrotherapy,  and 
other  measures  to  tone  the  nervous  system  should  not  be 
neglected.  The  physician  must  assume  complete  control,  and 
regulate  minutely  the  mode  of  life,  and  strictly  enforce  a 
sufficient  diet  and  proper  hygiene. 

In  the  advanced  stage  the  patient  should  be  isolated,  and 
given  a  gentle  but  firm  nurse.  If  the  stomach  is  intolerant, 
rectal  nourishment  should  be  used ;  and  milk,  eggs,  and  meat 
juices,  etc.,  should  be  given  by  the  mouth  as  soon  as  the 
vomiting,  which  is  a  rare  complication,  is  under  control. 
Absolute  rest  in  a  warm  bed,  systematic  feeding,  using 
authority  rather  than  the  stomach-tube,  massage,  electricity, 
hydrotherapy,  are  the  elements  of  the  combined  rest-cure. 
Few  symptoms  require  drugs  for  their  control,  and  it  is  a  bad 
plan  to  get  these  patients  accustomed  to  their  employment 
and  dependent  upon  them.  Supplementary  chemical  treat- 
ment with  pepsin  and  with  hydrochloric  acid  may  be  of  some 
aid  in  securing  the  digestion  of  a  sufficient  quantity  of  food 
in  the  beeinniner  of  the  treatment. 


V.  GASTRALGIA  NERVOSA. 

Gastralgia  is  an  intermittent,  painful  affection  of  the  stom- 
ach, occurring  in  paroxysms  independent  of  the  period  of 
functional  activity  or  of  the  existence  of  another  disease  of 
the  stomach.  It  is  in  its  nature  the  gastric  cry  of  an  irritated 
nerve-ending  or  nerve-center — a  pneumogastric  neuralgia. 


276  DISEASES  OF  THE   STOMACH. 

Etiology. — Paroxysmal  gastric  pain  may  be  symptomatic, 
reflex,  central,  or  nenralgic. 

Symptomatic  paroxysms  of  gastric  pain  occur  in  ulcer  of 
the  stomach,  in  cancer,  in  obstructive  and  myasthenic  reten- 
tion, in  acute  (toxic  or  mjxotic)  and  chronic  (h}-persthenic 
and  atrophic)  gastritis,  in  adenohypersthenia  gastrica,  in  gas- 
tric spasm  and  spasm  of  the  orifices,  in  perigastritis  and  peri- 
gastric adhesions,  and  in  gastroptosis.  The  paroxysms  of  pain 
associated  with  these  diseases  should  not  be  confounded  with 
gastralgia  nervosa,  nor  should  painful  gastric  cramps  be 
described,  as  is  done  by  some  authors,  under  the  heading 
"  gastralgia,"  which  is  a  neuralgia  of  the  stomach. 

Reflex  gastric  pain  is  usually  spasmodic  and  not  neuralgic. 
Gastralgia,  however,  is  very  seldom  caused  reflexly  by  dis- 
eases of  the  generative  organs,  of  the  liver,  of  the  spleen,  of 
the  pancreas,  and  of  the  bladder. 

Painful  gastric  crisis  may  be  produced  by  diseases  involv- 
ing the  nuclei  of  origin  of  the  pneumogastrics  (tabes,  multiple 
sclerosis,  myelitis,  and  tumors),  by  compression  of  the  trunks 
of  the  pneumogastric  nerves,  and  by  irritation  of  the  periphe- 
ral endings  of  the  pneumogastrics  or  of  the  sympathetic 
ganglia. 

Idiopathic  gastralgia  nervosa  is  not  a  frequent  disease,  and 
is  due  to  the  same  causes  as  other  neuralgias.  Neurasthenia, 
malaria,  syphilis,  chlorosis,  oligocythemia,  uricemia,  and  auto- 
intoxication are  the  most  common  causes,  and  masturbation 
and  sexual  excesses  are  often  associated, seemingly  in  a  causal 
relation,  with  the  trouble.  Chlorosis  and  oligocythemia  fre- 
quently cause  adenohypersthenia  gastrica,  sometimes  hyperes- 
thesia, and,  rarely,  gastralgia.  The  abuse  of  tobacco  is  respon- 
sible for  some  of  the  cases  in  men,  but  gastralgia  ner\'osa  is 
most  common  in  women  between  the  fifteenth  and  thirtieth 
years  who  belong  to  neuropathic  families.  It  sometimes  fol- 
lows typhoid  fever  and  influenza.  Malarial  gastralgia  maybe 
periodical,  accompanying  the  chill  or  taking  its  place. 

Clinical  Description. — At  the  bedside,  gastralgia  is  easily 
separable  into  two  forms — the  mild  and  the  severe.  In  the 
mild  form  the  pain  is  bearable,  closely  limited  to  the  re- 
gion of  the  stomach,  and  of  short  duration.  There  is  little 
or  no  prodromal  nausea  or  salivation,  but  only  a  slight  feeling 
of  distention,  to  usher  in  the  attack.  There  is  no  fermen- 
tation, and  the  variations  of  secretion  do  not  get  bej-ond  the 
normal  limits.  There  may  be  a  small  quantit)' of  gastric  juice 
containing  a  trace  of  free  hydrochloric  acid  in  the  stomach, 
if  the  attack  should  occur  during  the  period  of  gastric  repose; 


THE    SENSORY  DYNAMIC  AFFECTIONS.  277 

and  its  presence  may  be  best  explained  as  the  result  of  the 
vasomotor  dilatation  that  is  frequent  in  parts  affected  by- 
neuralgia.  During  the  attack  the  stomach  is  but  little  dis- 
tended or  contracted,  and  the  organ,  apart  from  a  slight 
sensitiveness  on  pressure,  yields  no  abnormal  physical  signs. 
The  attack  is  usually  unassociated  with  heartburn,  or  pyrosis, 
and  ends  with  a  moderate  sensation  of  hunger,  slight  drowsi- 
ness, and  a  free  discharge  of  clear  urine  of  low  specific  grav- 
ity, of  slight  acidity,  and  which  precipitates  the  earthy  phos- 
phates on  heating.     This  is  the  mild  form. 

The  duration  of  the  mild  attacks  is  short — seldom  longer 
than  a  few  hours.  The  pain  is  often  moderated  by  strong 
pressure  over  a  large  area  of  the  epigastrium,  and  it  may  be 
rapidly  and  completely  relieved  by  the  pure  sedative  influence 
of  anodal  galvanization. 

The  paroxysms  of  the  severe  form  usually  begin  with  a 
well-marked  sensation  of  distention  of  the  stomach  and  with 
loss  of  appetite.  The  beginning  is  violent,  sudden,  without  ade- 
quate local  cause,  and  independent  of  the  functional  activity 
of  the  stomach.  Then  the  severe,  tearing,  cutting,  throbbing, 
aching,  or  burning  pain  appears  in  the  epigastrium  and  radi- 
ates through  the  abdomen,  behind  into  the  back,  along  the 
intercostal  nerves,  and  under  the  sternum  into  the  lower  part 
of  the  esophagus.  The  irradiated  pains  may  be  very  severe 
and  accompanied  by  a  pinched,  anxious,  perspiring  face,  cold 
extremities,  retracted  abdomen,  and  a  small,  jerky  pulse, 
usually  frequent,  sometimes  slow,  with  pulsation  of  the 
abdominal  aorta.  Or  the  patient  may  be  doubled  together 
with  contracted  abdominal  muscles,  the  breathing  being  thor- 
acic and  shallow.  After  a  variable  duration  the  pain  subsides, 
and  the  exhausted  patient  may  fall  asleep.  During  the  attack 
the  urine  is  of  high  specific  gravity  and  but  little  is  secreted. 
The  paroxysm  may  last  several  hours  and  may  end  in  vomit- 
ing; or  the  pain  may  gradually  cease  with  the  discharge  of  a 
large  quantity  of  clear,  or  sometimes  slightly  clouded,  urine 
of  the  same  character  as  in  the  mild  attack. 

The  violent  attacks  may  last  one  or  two  days,  or  only  a  {^vj 
hours,  and  may  recur  after  long,  short,  or  irregular  intervals. 
The  pain  is  calmed  by  neither  alkalies  nor  albuminous  food, 
and  the  paroxysms  occur  regardless  of  the  functional  activity 
or  repose  of  the  stomach.  If  they  occur  during  the  period  of 
digestion,  the  attack  may  end  with  critical  vomiting;  but  the 
attacks  recur  in  relation  with  the  exacerbations  of  the  causa- 
tive disease  and  are  most  frequent  after  cerebral  or  physical 
fatigue. 


2/8  DISEASES  OF  THE  STOMACH. 

Diagnosis. — Intermittent  paroxysmal  attacks  of  gastric 
pain,  beginning  suddenly,  becoming  rapidly  intense,  in  no 
constant  relation  with  the  taking  of  food  or  with  the  evolution 
of  gastric  digestion,  unassociated  with  abnormal  functional 
and  bacteriological  signs,  occurring  in  the  absence  of  any 
other  disease  of  the  stomach,  separated  by  intervals  of  normal 
painless  digestion,  are  so  characteristic  that  the  diagnosis  may 
be  easily  made.  But  the  etiological  diagnosis  may  present 
great  difficulties,  and  a  careful  search  should  be  made,  and 
the  diseases  mentioned  under  etiology  should  be  excluded, 
before  the  gastralgia  is  pronounced  to  be  primary  and  idio- 
pathic— a  form  which  close  study  will  prove  to  be  rare. 

Differential  Diagnosis. — The  differentiation  of  gastralgia 
from  other  painful  paroxysmal  diseases  must  often  be  made 
by  exclusion.  It  may  be  confounded  with  some  of  the  pain- 
ful gastric  diseases  or  with  painful  diseases  of  other  abdominal 
organs.  It  may  also  be  confounded  with  intercostal  neuralgia 
and  rheumatism  of  the  abdominal  muscles. 

Intercostal  neuralgia  may  be  due  to  the  same  causes  as 
gastralgia,  and  is  frequent  in  anemic  girls,  and  is  most  common 
on  the  left  side.  The  intercostal  neuralgic  pain  may  be 
severe  and  may  resemble  in  location  and  intensity  that  of  gas- 
tralgia. The  neuralgia  of  the  lower  intercostal  nerves  may 
be  concentrated  in  the  epigastrium.  The  area  of  the  radia- 
tions is  different;  the  patient  locates  the  intercostal  pain  in 
the  thoracic  and  the  abdominal  walls,  and  the  whole  course, 
or  special  points  of  the  intercostal  nerve,  or  nerves,  are  painful 
on  pressure.  The  intercostal  neuralgia,  being  superficial,  is 
more  readily  relieved  by  sedative  galvanization.  The  inter- 
costal pains  of  spinal  disease  are  bilateral  and  constricting, 
and  are  associated  with  the  special  signs  of  the  spinal  trouble. 
But  it  should  not  be  forgotten  that  the  pain  of  gastralgia  may 
radiate  along  the  intercostal  nerves. 

Myalgia  may  be  localized  in  the  epigastrium  and  the  left 
hypochondrium.  In  myalgia  and  gastralgia  the  abdominal 
muscles  are  contracted,  and  the  pain  may  be  paroxysmal  and 
similar  in  location.  The  myalgia  is  relieved  or  increased, 
respectively,  by  relaxation  or  contraction  of  the  affected 
muscles.  The  painful  area  corresponds  with  the  location  of 
the  muscles,  and  the  extension  of  the  trouble  to  the  lumbar 
or  other  muscles  outside  of  the  gastric  area  would  be  a  dis- 
tinctive characteristic.  Muscular  rheumatism,  as  Leube  has 
shown,  may  be  accompanied  by  fever,  and  there  is  no  increase 
of  temperature  in  gastralgia. 

Gall-stone  colic,  which  may  be  itself  the  cause  of  gastralgic 


THE   SENSORY  DYNAMIC  AFEECTIONS.  279 

crises,  probably  through  irritation  of  the  solar  plexus,  may 
be  mistaken  for  gastralgia.  In  cholelithiasis  the  pain  is  to 
the  right  of  the  median  line ;  radiates  sometimes  also  to  the 
right  and  to  the  region  of  the  right  scapula  ;  a  painful  pres- 
sure-point to  the  right  of  the  twelfth  dorsal  vertebra  is  com- 
mon ;  the  liver  maybe  enlarged  and  tender;  the  epigastric 
tenderness  corresponds  to  the  area  and  the  form  of  the  left 
lobe;  the  gall-bladder  may  be  distended,  and  may  present  a 
visible  and  palpable  tumor,  and  give  rise  to  friction-sounds 
during  the  movements  of  the  diaphragm ;  there  may  be 
jaundice  and  fever,  and  gall-stones  may  be  found  in  the 
feces.  The  attacks  of  hepatic  colic  are  often  closely  related  to 
dietetic  excesses.  In  atypical  cases  all  these  differential 
characters  may  be  absent,  and  a  seemingly  typical  gastralgia 
may  later  prove  to  be  a  no  less  typical  gall-stone  colic. 

Intestinal  colic  is  not  likely  to  be  be  mistaken  for  gas- 
tralgia, except  when  located  in  the  transverse  colon.  There 
may  be  signs  of  chronic  lead-poisoning  or  a  history  of  con- 
stipation. The  abdomen  is  fuller  than  in  gastralgia ;  the 
intestine  can  be  felt  distended  with  gas,  or  it  rolls  like  a 
hard  cord  under  the  finger.  The  radiation  is  into  the  lumbar 
region  or  over  the  sacrum,  and  the  paroxysm  ends  with  the 
evacuation  of  the  bowel,  which  often  contains  mucous  shreds 
or  hydrosulphuric  acid  gas.  The  intestinal  pain  is  also  dis- 
tinctly peristaltic,  or  spasmodic,  and  the  point  of  the  greatest 
intensity  follows  the  course  of  the  bowel. 

Hyperesthesia  gastrica  is  easily  differentiated  from  gastral- 
gia. The  pain  of  hyperesthesia  is  not  spontaneous,  is  excited 
immediately  by  the  contact  of  the  ingested  food,  and  it  sub- 
sides with  the  evacuation  of  the  stomach. 

Adenohypersthenia  gastrica  and  chronic  hypersthenic  gas- 
tritis are  frequently  mistaken  for  gastralgia.  The  hyper- 
chlorhydria,  or  hyperchylia,  at  once  excludes  gastralgia. 
The  paroxysms  begin  and  develop  more  slowly,  after  the 
ingestion  of  food,  and  in  close  relation  with  the  evolution  of 
secretion.  The  pain  is  moderated  by  alkalies,  by  water,  and 
by  albuminous  food,  and  it  is  digestive.  The  functional 
signs,  however,  in  all  doubtful  cases,  are  absolutely  conclu- 
sive, for  hyperchylia  and  hyperchlorhydria  exclude  gastralgia. 
Paroxysmal  pain  characterizes  a  clinical  form  of  chronic 
atrophic  gastritis;  but  the  achylia, which  always  accompanies 
this  disease,  is  never  found  in  gastralgia. 

The  differentiation  of  atypical  ulcer  and  gastralgia  may  be 
difficult  or  impossible.  The  typical,  painful  paroxysms  of 
ulcer,  excited  by  food  and  digestion,  and  relieved  by  the 
evacuation  of  the  stomach,  present  no  difficulty.    Neither  can 


28o  DISEASES  OF  THE  STOMACH. 

there  be  any  doubt  when  there  are  strictly  circumscribed 
and  painful  epigastric  and  dorsal  pressure-points,  and  when 
the  pain  is  increased  by  the  movements  of  the  body  and  is 
relieved  by  rest  in  a  particular  position.  But  the  ulcer  may 
be  atypical  in  its  expression,  and  may  leave  the  physician  in 
doubt  after  all  the  etiological,  subjective,  and  objective  signs 
have  been  weighed.  In  the  absence  of  the  possible  conclusive 
functional  signs,  the  case  should  be  treated  as  ulcer  until  more 
light  can  be  obtained.  Such  a  course  protects  the  physician 
and  gives  the  patient  the  benefit  of  all  doubt. 

Epigastric  pain  may  be  caused  by  small  herniae  in  this 
region,  by  cysts  or  carcinoma  of  the  pancreas,  by  pancrea- 
titis, by  pancreatic  calculi,  by  duodenal  ulcer,  and  by  peri- 
gastric adhesions.  When  the  pain  is  due  to  adhesions  of  the 
stomach,  it  recurs  with  greater  regularity  than  in  gastralgia, 
and  it  may  be  produced  by  inflating  the  stomach  or  by  over- 
loading it  with  food. 

Treatment. — The  treatment  of  gastralgia  is  etiological  and 
symptomatic.  To  relieve  the  pain,  anodyne  and  sedative  treat- 
ment is  indicated.  In  the  mild  form,  ten  grains  of  antipyrin 
often  promptly  relieve  the  pain.  If  the  pain  be  very  severe,  it 
is  best  to  give  at  once  the  sovereign  remedy,  which  is  a  pre- 
paration of  opium, — morphin  or  codein, — administered  hypo- 
dermically  or  by  the  mouth.  Hot  poultices  (or  a  hot-water 
coil  over  wet  flannel)  should  be  placed  over  the  stomach,  and 
hot  drinks  should  be  given  by  mouth.  The  deodorized  tinc- 
ture of  opium  is  also  a  good  preparation.  Belladonna, 
Hoffman's  anodyne,  and  chloroform  water  have  also  been 
reconmiended,  but  are  not  trustworthy.  In  the  recurring 
mild  attacks,  aconite  and  gelsemium  may  prove  serviceable, 
and  act  best  when  given  simultaneously  in  small,  repeated 
doses.  We  usually  order  a  combination  of  codein  (^  of  a  gr.), 
ext.  cannabis  indica  (y^^  of  a  gr.),  atropin  (^^  of  a  gr.),  and 
aconitia  {-^\^  of  a  gr.).  If  malaria  be  tlie  cause, the  attacks  of 
gastralgia  are  periodical.  Quinin  cures  these  cases  promptly. 
We  prefer  the  muriate  when  the  drug  is  given  by  mouth,  and 
it  should  be  administered  in  a  single  dose  (lo  to  15  grs.),  five 
hours  before  the  time  for  the  recurrence  of  the  attack.  Or 
the  quinin  may  be  given  by  rectum,  the  following  formula 
being  a  good  one  : 

li  •      Quininre  muriat., grs.  x-xx 

Morphina;  muriat.,       gr.  yi—% 

Sodii  chloridi,       grs.  v 

Aq.  amyli, ^  ij. 

M.  et  ft.  sol. 

SiG. — Inject  slowly  into  the  rectum  three  hours  before  the  attack. 


THE   SENSORY  DYNAMIC  AFFECTIONS.  281 

Or  the  bimuriate  of  quinin  (grs.  xxx  to  aq.  dist.  5j)  may- 
be given  hypodermically,  the  muriate  of  morphia  being 
combined  with  the  quinin  if  it  be  desirable.  Administer 
15  to  20  minims  two  hours  before  the  time  for  the  attack.  It 
is  our  custom  to  combine  with  the  quinin,  during  the  time  of 
the  administration  of  full  doses  (three  to  five  days),  either 
morphin  or  codein,  which  act  as  synergists. 

Galvanization  often  gives  prompt  relief,  and  is  indicated 
where  it  is  advisable  to  avoid  the  use  of  morphin.  The  anode 
(100  sq.  cm.)  is  placed  over  the  stomach,  and  the  cathode,  of 
the  same  size,  is  held  to  the  left  of  the  dorsal  spine.  A  cur- 
rent of  three  to  five  milliamperes  is  slowly  and  gradually 
turned  on,  is  allowed  to  flow  from  five  to  ten  minutes  (until 
the  pain  ceases),  and  is  slowly  reduced  to  zero  before  remov- 
ing the  electrodes,  in  order  to  obtain  the  pure  sedative  polar 
influence  of  the  anode.  Intragastric  galvanism  may  be  tried 
by  those  who  prefer  this  method  of  using  it.  It  matters 
little  whether  intragastric  or  epigastric  galvanism  is  em- 
ployed, provided  it  be  administered  so  as  to  get  a  sedative 
influence.  During  the  intervals,  sedative  galvanism  and 
aconitia  give  excellent  results,  and  the  special  indications 
furnished  by  the  etiology  of  the  neuralgia  should  be  met — 
forbidding  the  use  of  tobacco  and  sexual  excesses,  building 
up  the  blood  and  nutrition  and  the  nervous  system,  curing 
the  malaria,  and  preventing  auto-intoxication. 


VI.  HYPERESTHESIA  GASTRICA. 

Like  gastralgia,  hyperesthesia  may  be  only  a  symptom  or 
it  may  be  a  primary  affection  of  the  stomach.  In  health  a 
person  is  unconscious  of  the  contact  of  the  normal  contents  of 
the  stomach  with  the  gastric  mucous  membrane.  In  simple 
hyperesthesia  gastrica  the  mucous  membrane  is  excessively 
sensitive  without  the  presence  of  either  an  anatomical  lesion 
or  of  a  disorder  of  secretion.  The  patient  becomes  conscious, 
often  painfully  conscious,  of  the  contact  impressions,  which 
in  health  are  unperceived.  The  disease  is  analogous  to 
hyperesthesia  of  the  skin,  and  differs  essentially  from  gas- 
tralgia, which  is  a  pneumogastric  neuralgia. 

Etiology. — Hyperesthesia  gastrica  may  be  a  symptom  of 
ulcer  and  of  both  adenohypersthenia  gastrica  and  chronic 
hypersthenic  gastritis.  As  a  distinct,  unassociated  affection 
of  the  stomach   it  occurs  in   diseases  of  the  central  nervous 


282  DISEASES  OF  THE  STOMACH. 

system,  in  chlorosis,  in  anemia,  in  the  artliritic,  and  in  the 
neuropath.  Gastric  hyperesthesia  may  be  the  first  and  only 
symptom  of  uremia.  It  may  be  a  monosymptom  of  hysteria 
or  may  coexist  with  other  manifestations  of  this  psychosis. 
It  may  be  excited  by  irritant  foods  and  drinks,  by  tea,  coffee, 
tobacco,  excesses  in  venery,  onanism,  and  masturbation.  It 
is  a  common  sign  of  narcotic  drug  habits,  and  may  be  pro- 
duced by  chloroform  narcosis.  It  is  a  symptom  of  absinthe 
alcoholism,  is  not  rare  during  convalescence  from  exhausting 
diseases,  sometimes  precedes  and  sometimes  follows  gastralgia 
nervosa,  and  may  be  induced  by  prolonged  fasting  and  by  the 
protracted  use  of  an  exclusive  and  insufficient  diet.  Hyper- 
esthesia gastrica  is  a  common  result  of  an  insufficient  or  ex- 
clusive diet,  but  the  basis  of  the  trouble  is  most  frequently  a 
neuropathic  or  an  arthritic  soil. 

Clinical  Description. — In  the  mild  form,  immediately  after 
the  introduction  of  food  there  is  a  peculiar  uneasiness  and 
discomfort,  a  feeling  of  local  irritation,  and  tingling,  shooting 
pains.  These  symptoms  continue  throughout  the  period  of 
digestion,  and  disappear  with  the  evacuation  of  the  stomach. 

In  the  well-developed  form  the  contact  of  food  produces 
immediate  pain,  which,  when  severe,  may  excite  nausea  and 
vomiting.  The  symptoms  are  excited  alike  by  fluids  and  by 
solids;  indeed,  fluids  containing  an  excitant  seem  to  produce 
a  more  diffused  pain.  The  pain,  often  preceded  and  accom- 
panied by  a  sensation  of  weight  and  fullness,  continues 
throughout  the  period  of  gastric  activity;  and  nausea,  a  sen- 
sation of  cold  and  heat,  conscious  gastric  arterial  pulsation, 
and  vomiting  convince  the  patient  of  the  existence  of  a  very 
serious  organic  disease.  When  water  is  introduced  through 
the  tube  into  the  stomach,  retching  and  vomiting  are  imme- 
diately and  almost  invariably  excited.  Through  fear  of  pain, 
one  article  of  food  after  another  is  refused  ;  through  vomiting 
the  supply  of  nutriment  may  be  reduced  below  the  needs  of 
nutrition,  and  emaciation  may  become  progressive.  There 
may  be  no  emaciation,  or  there  may  be  emaciation  propor- 
tionate to  the  quantity  of  food  lost  by  vomiting  and  to  the 
insufficiency  of  the  diet.  Gastric  hyperesthesia  is  the  fore- 
runner of  anorexia  nervosa  and  of  habitual  vomiting. 

During  the  period  of  gastric  repose  there  is  often  a  sensa- 
tion of  emptiness,  often  decidedly  unnerving  and  unbearable, 
and  associated  with  slight  vertigo  and  faintness.  A  peculiar 
form  of  hyperesthesia  gastrica  is  manifested  by  short,  painful 
paroxysms  (fifteen  to  thirty  minutes),  which  occur  as  soon  as 
the  stomach  becomes  empty.     The  pain   may  be  relieved  by 


THE   SENSORY  DYNAMIC  AFFECTIONS.  283 

food,  but  it  is  not  relieved  by  soda,  the  sodium  chlorid  formed 
increasing  the  pain  and  often  exciting  nausea.  It  is  probable 
that  the  pain  is  produced  by  the  action  of  free  HCl  on  the 
oversensitive  gastric  mucosa,  secretion  continuing  after  the 
evacuation  of  the  contents  of  the  stomach  into  the  duodenum. 
In  some  cases  sensation  is  dissociated,  either  in  the  periphery 
or  in  consciousness.  There  may  be  a  morbid  sensibility  to 
slight  changes  in  the  temperature  of  the  food,  the  painful  im- 
pression of  contact  being  momentarily  less  pronounced;  or 
the  gastric  contents  may  produce  now  a  sensation  of  cold, 
now  burning,  now  pain,  and  these  sensations  are  sometimes 
spontaneous  and  perceived  when  the  stomach  is  empty. 

In  hyperesthesia  gastrica  the  skin  over  the  epigastrium  is 
often  very  sensitive.  Deep  pressure  reveals  the  morbid  sen- 
sibility of  the  whole  stomach,  there  being  no  circumscribed 
painful  points.  The  area  of  diffused  tenderness  is  sharply 
limited  and  corresponds  closely  with  the  size  and  form  of  the 
stomach.  By  moderate  vertical  pressure  with  the  fingers  the 
size  and  position  of  the  stomach  may  frequently  be  deter- 
mined with  exactness. 

The  secretory  function  of  the  stomach  is  normal.  The 
contents,  after  the  test-breakfast,  reveal  normal  chemical, 
microscopical,  and  bacteriological  signs.  There  may  be  in- 
constantly a  small  excess  or  a  slight  diminution  of  free  HCl, 
which  may  be  plausibly  explained  by  the  accompanying  vaso- 
dilatation. 

Diagnosis. — The  pain  due  to  contact,  and  occurring  imme- 
diately and  invariably  after  the  ingestion  of  food,  or  as  soon 
as  the  stomach  is  empty,  and  with  the  associations  detailed  in 
the  clinical  history,  and  with  the  normal  functional  signs,  leave 
little  room  for  doubt  as  to  the  nature  of  the  trouble.  The 
etiology  may  also  aid  in  the  diagnosis.  The  pain  is  excited 
by  the  contents  of  the  stomach — the  food,  digestive  products, 
and  the  free  hydrochloric  acid.  Consequently  the  symptoms 
are  digestive,  occur  regularly,  and  for  a  number  of  days  or 
weeks  after  meals,  or  at  the  moment  when  the  stomach  first 
becomes  empty.  Hyperesthesia  gastrica,  consequently,  dif- 
fers widely  from  the  paroxysms  of  gastralgia  nervosa. 

Differential  Diagnosis. — The  only  diseases  likely  to  be 
confounded  with  hyperesthesia  gastrica  are  atypical  ulcer, 
adenohypersthenia  gastrica,  and  hypersthenic  gastritis.  In 
adenohypersthenia  and  in  the  hypersthenic  form  or  stage  of 
gastritis,  the  pain  does  not  occur  so  soon  after  the  ingestion 
of  food,  and  the  stomach  only  becomes  intolerant  toward 
the  height   of  secretion.     The  pain  is   also  in  strict  relation 


284  DISEASES  OF  THE  STOMACH. 

with  the  quality  of  the  food,  and  is  reheved  by  albuminous 
foods  and  by  alkalies.  In  hyperesthesia  the  pain  is  imme- 
diate, and  is  due  to  contact  and  not  to  functional  excitation, 
and  is  produced  by  all  sorts  of  food.  The  abnormal  chemi- 
cal si<^ns  characteristic  of  functional  and  organic  adenohyper- 
sthenia  are  absent. 

Ulcer  may  be  manifested  only  by  pain,  but  the  ulcer  pain 
has  distinctive  features.  Cases  where  the  pain  does  not  occur 
immediately  after  taking  food  present  no  difficulty.  But 
hyperesthesia  may  be  a  complication  of  ulcer.  Even  in  the 
absence  of  the  characteristic  relations  of  the  pain  of  ulcer  to 
the  quality  of  the  food,  to  the  evolution  of  secretion,  to  the 
movements  and  repose  of  the  body,  and  even  in  the  absence 
of  the  characteristic  circumscribed  epigastric  and  dorsal  pres- 
sure-points the  abnormal  functional  signs  of  ulcer  would  still 
be  conclusive.  Both  diseases  are  frequent  in  the  same  class 
of  patients,  and  if  there  is  doubt  after  weighing  all  the  signs, 
the  case  should  be  treated  as  ulcer. 

Treatment. — It  is  best  to  put  these  patients  at  once  to  bed. 
The  more  absolute  the  repose  of  body  and  mind,  the  more 
rapid  will  be  the  cure.  Sedative  galvanization,  applied  as  in 
the  treatment  of  gastralgia,  but  with  the  current  of  very  low 
density — as  two  milliamperes  with  an  electrode  lOO  sq.  cm., 
daily  sittings.  A  cold  compress  (Winternitz's  compress  is  the 
best)  should  be  kept  constantly  over  the  abdomen.  Nitrate 
of  silver  is  the  best  medicine,  and  often  acts  with  remarkable 
efficiency.  One  grain  shouldbe  dissolved  in  two  ounces  of 
distilled  water,  and  one  or  two  teaspoonsful  should  be  given 
three  times  a  day  on  an  empty  stomach.  It  is  often  unnec- 
essary to  continue  the  drug  longer  than  two  or  three  days. 
A  more  efficient  method  is  to  spray  or  douche  the  stomach 
with  a  solution  of  nitrate  of  silver.  In  our  experience,  the 
bromids  do  no  good. 

The  diet  should  be  non-e.xciting  and  indifferent  in  its  physi- 
ological action  on  the  stomach.  For  a  short  period  a  pure 
milk  diet  or  milk  and  lime-water  should  be  employed  ;  as 
soon  as  the  pain  is  controlled,  cereal  gruels,  soft-boiled  or 
poached  eggs,  and  meats,  vegetables,  and  other  foods  should 
be  added,  in  the  order  given  in  the  chapter  on  Diet  (Section 
III,  chap.  11).  Or  it  may  be  best  to  employ  e.xclusive  rectal 
feeding  for  a  few  days. 

The  etiological  treatment  will  demand  attention,  and  con- 
sists in  medication  directed  against  the  hysteria,  anemia, 
chlorosis,  neuropathic  or  arthritic  constitution,  and  the  cor- 
rection of  excesses  and  of  bad  habits. 


THE   DYNAMIC  AFFECTIONS   OF  SECRETION.  285 


CHAPTER  II. 
THE  DYNAMIC  AFFECTIONS  OF  SECRETION. 

Some  authors  deny  the  existence  of  persistent  disorders  of 
secretion  which  are  not  produced  by  an  anatomical  lesion  of 
the  gastric  mucosa,  and  the  majority  of  writers  consider  all 
the  dynamic  affections  of  secretion  to  be  neuroses.  In  our 
opinion  both  these  contentions  are  erroneous.  There  is  no 
doubt  that  persistent  abnormalities  of  secretion  are  frequently 
functional  signs  of  the  anatomical  diseases  of  the  stomach. 
No  one  will  deny  that  secretion  may  be  disturbed  through 
the  nerves  which  control  it.  Prolonged  study  and  careful 
investigation  have  led  us  irresistibly  to  the  conclusion  that 
the  disorders  of  secretion  are  not  always  due  to  an  alteration 
of  the  mucosa  or  to  a  neurosis  of  the  vagosympathetic 
system. 

It  is,  furthermore,  the  custom  to  describe  a  very  special 
condition  of  the  stomach  as  a  distinct  disorder  of  secretion, 
or  neurosis  of  the  stomach.  This  condition  has  been  named 
"  continuous  secretion,"  or  gastrosuccorrhea,  or  Reichmann's 
disease,  and  it  may  be  either  periodical  (gastrosuccorrhea 
periodica)  or  continuous  (gastrosuccorrhea  continua  chronica). 
We  are  unable  to  convince  ourselves  that  continuous  gastro- 
succorrhea exists  as  a  dynamic  affection.  This  condition  of 
secretion  may  be  met  with  as  an  episode  in  obstruction  of  the 
pylorus,  in  myasthenia  with  secretory  irritation  due  to  the 
retention  of  the  contents  of  the  stomach,  or  in  the  hyper- 
sthenic form  of  chronic  gastritis.  It  is  not  a  distinct  morbid 
entity,  but  is  a  special  symptom — a  mere  complicating  condi- 
tion. Continuous  secretion,  in  our  opinion,  is  not  a  severe 
form  of  supersecretion  without  an  anatomical  lesion  of  the 
mucous  membrane,  nor  is  it  a  delayed  reaction  of  the  secre- 
tory nerves  to  the  excitation  produced  by  the  meals.  The 
normal  stomach  does  not  secrete  when  it  is  empty,  and,  at 
most,  only  10  to  20  c.c.  of  gastric  contents  can  be  removed 
when  the  tube  is  introduced  into  the  normal  stomach  in 
the  early  morning  before  breakfast;  but  sometimes  when 
the  tube  is  introduced  at  this  time  (even  when  the  stomach 
has  been  thoroughly  washed  out  the  evening  before  and 
left  empty)  it  will  be  found  that  the  stomach  contains  much 
more  than    20    c.c.  of   a    liquid    rich    in    hydrochloric    acid 


286  DISEASES  OF  THE  STOMACH. 

and  the  digestive  ferments.  This  is  considered  the  char- 
acteristic functional  sign  of  continuous  secretion.  The  sign 
exists,  but  we  maintain  that  its  interpretation  is  wrong. 
The  secretion  has  merely  accumulated  in  the  stomach 
(myasthenia,  pyloric  obstruction),  or  it  has  been  formed  as  a 
result  of  hypersthenic  gastritis,  or,  in  case  the  stomach  has 
not  been  washed  out,  it  may  have  been  excited  by  retained 
food  and  digestive  products.  The  evening  lavage,  or  lavage 
followed  by  a  few  days  of  rectal  feeding,  or  the  water  test, 
considered  in  combination  with  the  clinical  history  and  with 
the  other  objective  signs,  will  reveal  the  cause  of  the  gastro- 
succorrhea  and  demonstrate  its  non-existence  as  a  dynamic 
affection  of  the  stomach.  It  is  always  due  to  retention,  or  to 
hypersthenic  gastritis,  or  to  both. 

Unfortunately,  the  words  in  common  usage  are  unsuitable 
for  designating  the  dynamic  affections  of  secretion.  Super- 
acidity  (or  the  mongrel  word,  hyperacidity)  denotes  abnormal 
increase  of  the  acidity  of  the  contents,  whether  it  be  due  to 
hydrochloric  or  to  organic  acids.  Hydrochloric  superacidity 
is  more  exact,  but  the  term  is  also  used  to  denote  the  func- 
tional sien  of  certain  anatomical  diseases  of  the  stomach. 
The  same  objections  apply  to  subacidity.  Supersecretion 
denotes  an  increase  of  the  quantity  of  secretion,  whether  it 
be  a  particular  morbid  process  or  a  functional  sign.  Hyper- 
chlorhydria  and  hypochlorhydria  denote  a  pathological  in- 
crease or  decrease  of  hydrochloric  acid  in  the  filtrate  of  the 
gastric  contents  at  the  acme  of  digestion,  and  do  not  embrace 
all  the  secretory  disturbances  which  are  found  in  the  two 
classes  of  the  dynamic  affections.  In  order  to  avoid  con- 
fusion and  to  embody  an  exact  conception  of  their  nature,  we 
shall  divide  the  dynamic  affections  of  the  stomach  into  two 
large  classes,  and  describe  them,  in  keeping  with  references  in 
other  parts  of  this  book,  as  adenohypersthenia  gastrica  {aSijv, 
gland,  urAp,  excessive,  and  a<U-^o<;,  strength  ;  excessive  glan- 
dular activity)  and  adenasthenia  (a^'jV,  a,  and  (rMvoq)  gastrica. 
These  terms  denote  the  morbid  processes  which  are  mani- 
fested by  the  disturbances  of  secretion,  and  stand  in  clear 
relief  with  the  similarly  formed  terms,  myasthenia  gastrica 
and  neurasthenia  "-astrica. 


I.  ADENOHYPERSTHENIA  GASTRICA. 

Adenohypersthenia  gastrica  is  a  dynamic  affection  charac- 
terized by  the  secretion  of  a  gastric  juice  which  is  abnormally 


THE   DYNAMIC  AFFECTIONS   OF  SECRETION.  28/ 

rich  in  hydrochloric  acid  or  which  is  excessive  in  quantity. 
The  hyperchlorhydria  {urAp,  -^Xiupuq,  and  vdiop)  and  the  hyper- 
chylia  {p-ip,  excess,  and  /6»A<>?,  juice)  gastrica  are  due  neither 
to  an  anatomical  lesion  of  the  mucosa  nor  to  motor  insuffi- 
ciency. Achylia  (a  lack  of  juice)  gastrica  has  recently  been 
employed  by  Einhorn  to  denote  a  permanent  absence  of 
gastric  secretion,  and  the  similarly  formed  terms,  hyperchylia 
gastrica  and  hypochylia  gastrica,  may  be  used  t<5  denote  a 
pathological  increase  or  decrease  of  gastric  secretion.  Hyper- 
chylia gastrica  is  here  employed  to  designate  the  dynamic 
affection  of  the  stomach  which  is  characterized  by  super- 
secretion. 

Hyperchlorhydria  and  hyperchylia  gastrica  are  closely 
related  in  their  etiology,  and  hyperchlorhydria  may  be  the 
forerunner  of  hyperchylia ;  but  this  does  not  establish  the 
identity  of  the  two  affections.  The  one  may  be  a  sequel  of 
the  other,  but  hyperchylia  gastrica  may  be  milder  than  the 
severe  cases  of  hyperchlorhydria,  and  may  not  be  accom- 
panied at  the  acme  of  the  digestion  of  a  test-meal  by  hydro- 
chloric superacidity.  The  one  is  only  a  qualitative  modification 
of  secretion,  and  the  other  is  essentially  a  quantitative  disturb- 
ance. The  two  affections  differ  in  their  subjective  manifesta- 
tions, in  their  physical,  functional,  and  bacteriological  signs, 
and  in  their  treatment.  Hyperchlorhydria  is  always  diges- 
tive; hyperchylia  gastrica  may  be  digestive  or  paroxysmal. 

(A)  HYPERCHLORHYDRIA. 

The  causes  of  hyperchlorhydria  are  those  common  to  a 
large  number  of  other  diseases  of  the  stomach,  and  are  as 
often  found  in  the  constitution  and  temperament  as  in  the 
mode  of  life  and  the  alimentation.  The  abuse  of  condi- 
ments, the  eating  of  large  quantities  of  red  meats,  and  imper- 
fect mastication  are  common  causes.  The  disease  is  most 
frequent  in  youth  and  manhood,  most  of  the  cases  occurring 
between  the  ages  of  fifteen  and  forty.  Sex  seems  to  be  with- 
out influence.  Like  other  dynamic  affections,  it  is  most  fre- 
quent in  the  arthritic  and  the  neuropath  :  in  neurasthenia,  in 
hysteria,  and  in  melancholia.  According  to  our  observation, 
it  is  quite  frequently  associated  with  intestinal  auto-intoxica- 
tion. It  is  common  in  cholelithiasis,  in  renal  lithiasis,  in 
chlorosis,  and  in  chronic  tobacco-poisoning.  It  is  frequent  in 
chronic  malaria,  even  before  quinin  has  been  taken. 

Mental  and  moral  causes  play  an  important  part.  Cerebral 
fatigue  may  mark  the  beginning  of  the  trouble,  and  illustrates 


288  DISEASES  OF  THE  STOMACH. 

the  close  relations  existing  between  the  brain  and  the  abdomi- 
nal sympathetic,  on  which  Leven  has  laid  so  much  stress. 
It  is  very  frequent  among  students.  Prolonged  excitement, 
worr}%  and  excesses  of  all  sorts  are  other  causes.  There  is 
no  distinct  relation  between  the  disorder  of  secretion  and  the 
nature  of  the  cause. 

Clinical  Description. — Ilyperchlorhydria  may  be  latent,  re- 
sembling in  this  respect  many  other  diseases  of  the  stomach, 
or  the  subjective  manifestations  may  occur  intermittently,  in 
spite  of  the  unbroken  continuity  of  the  digestive  secretory  irri- 
tation. The  trouble  may  begin  suddenly  after  a  particular  meal ; 
or  it  may  develop  more  gradually,  a  meal  composed  chiefly  of 
starches,  cereals,  sweets,  vegetables,  fruits,  and  fat  causing 
discomfort  and  pain  at  the  height  of  gastric  digestion. 

The  symptoms  are  digestive,  and  are  in  strict  relation  to 
the  evolution  of  secretion.  In  a  mild  attack,  which  is  the  rule 
after  a  small  meal,  such  as  a  breakfast  composed  of  a  cereal, 
eggs  or  meat,  and  cafe  an  lait,  there  is  slight  discomfort 
and  uneasiness  in  the  stomach,  which  usually  begin  with  the 
appearance  of  free  HCl  in  the  contents ;  and,  later,  there  may 
be  acid  eructations,  heartburn,  or  even  severe  pain — all  of 
which  disappear  with  the  evacuation  of  the  stomach.  The 
severe  attacks,  which  occur  chiefly  after  a  meal  the  action 
of  which  is  somewhat  irritating  and  leaves  a  large  quantity 
of  hydrochloric  acid  free  or  which  was  eaten  when  tired, 
are  accompanied  by  uneasiness,  heartburn,  eructations  of  a 
bitter,  sour  fluid,  severe  pain,  and  sometimes  vomiting.  The 
intensity  of  the  symptoms  keeps  pace  with  the  evolution  of 
secretion  and  of  digestion.  The  evacuation  of  the  stomach 
marks  the  end  of  the  attack.  The  pain  is  most  intense  dur- 
ing the  course  of  digestion,  when  free  HCl  is  greatest,  and  is 
temporarily  relieved  by  nitrogenous  food,  and,  more  perma- 
nently, by  a  full  dose  of  an  alkali.  The  appetite  is  good 
and  thirst  is  almost  invariably  intense.  In  some  cases  the 
local  digestive  symptoms  are  accompanied  by  the  symptoms 
of  general  neurasthenia,  which  are  most  prominent  during 
digestion.  The  disease  is  a  predisposing  cause  of  ulcer,  and, 
unless  arrested  early,  is  likely  to  end  in  hypersthenic  gastritis. 

The  subjective  manifestations,  which  are  exclusively  diges- 
tive, may  be  continuous,  remittent,  or  intermittent,  with 
intervals  during  which  digestion  is  painless.  The  digestive 
secretory  irritation  continues  from  day  to  day,  with  occasional 
exacerbations  ;  but  in  the  early  period  of  the  affection,  under 
the  influence  of  rest  and  a  bland  diet,  secretion  may  inter- 
mittent! \'  become  normal. 


THE   DYNAMIC  AFFECTIONS    OF  SECRETION.  289 

The  functional  signs  are  characteristic.  The  motor  function 
is  usually  normal  after  a  test-meal ;  after  a  large  meal,  accom- 
panied by  severe  pain,  pyloric  spasm  may  delay  evacuation. 
The  motor  function  is  excited  by  the  excessively  acid  con- 
tents, and  the  stomach  should  become  empty  more  rapidly 
than  in  health  ;  but  the  hyperesthesia  of  the  pylorus  and  of  the 
duodenum  may  prevent  the  rapid  evacuation  by  producing 
spasm  of  the  pylorus.  There  is  no  morning  splashing,  and 
usually  there  is  no  splashing  half  an  hour  after  drinking  a 
glass  of  water  on  an  empty  stomach.  If  splashing  can  be 
elicited  duruig  the  digestive  period  it  is  circumscribed,  and 
never  extends  beyond  the  normal  limits  of  the  stomach. 
There  is  no  motor  insufficiency,  except  the  occasional  and 
slight  stagnation  which  may  result  from  pyloric  spasm.  After 
the  water-test  the  stomach  will  be  found  empty  within  the 
normal  period,  and  the  stagnation,  if  it  occurs,  is,  con- 
sequently, not  due  to  myasthenia. 

The  resting  stomach  will  be  found  empty.  Albumins  are 
digested  with  unusual  rapidity.  At  the  end  of  two  hours  the 
meat  of  the  test-meal  of  Germain  See  is  almost  completely 
dissolved,  and  the  few  fibers  found  with  the  microscope  are 
undergoing  disintegration;  propeptones  are  abundant,  and 
the  biuret  and  Almen  reactions  for  peptones  are  plainly  posi- 
tive. Starch  is  not  so  well  digested  as  in  health.  The  inhibi- 
tion of  salivary  digestion  occurs  so  much  earlier  than  in  health 
that  Lugol's  solution  gives  a  blue  or  purplish-red  coloration 
when  added  to  the  filtered  contents.  The  contents  obtained 
one  hour  after  a  test-breakfast  are  excessively  acid  (normal, 
60),  composed  of  both  free  (H)  and  (C)  combined  HCl.  Free 
HCl  appears  much  earlier  (ten  minutes)  in  the  contents  after  the 
test-breakfast  than  in  normal  secretion  (twenty  to  thirty  nu"n- 
utes);  and  also  about  twice  as  early  as  in  health  after  the  See 
and  after  the  Riegel  test-dinners.  Albumin  digestion  is  very 
active  and  rapid,  and  combined  HCl  may  be  excessive,  even 
though  there  should  be  no  obstructive  stagnation  and  conse- 
quent accumulation  of  digestive  products.  The  hydrochloric 
acidity  is  excessive  during  the  decline  of  digestion.  Conse- 
quently secretion  may  be  rapid,  and  very  rich  in  both  hydro- 
chloric acid  and  digestive  ferments.  There  are  no  organic  acids, 
or  only  unimportant  traces.  The  filtered  contents  are  rich  in 
ferments  and  possess  very  high  digestive  and  milk-coagulating 
powers.  The  tube  digestions  are  very  rapid — the  acidulated 
50  per  cent,  dilution  often  digesting  as  rapidly  as  the  filtrate  of 
the  normal  contents.  Labferment  and  labzymogen  are  both 
very  active.  The  mucus,  and  the  epithelium,  and  the  germ 
19 


290  DISEASES  OF   THE   STOMACH. 

growtli  are  not  excessive  nor  abnormal.     The  tube  fermenta- 
tion tests  are  negative. 

The  epigastrium  is  painful  on  pressure  during  the  digestive 
attacks,  and  more  markedly  so  over  the  pylorus.  The  skin 
may  be  hyperesthetic.  During  the  interval  while  the  stomach 
is  empty  there  is  much  less  tenderness  and  hyperesthesia. 

The  urine  formed  during  the  period  of  gastric  digestion  is 
poor  in  chlorids,  nearly  neutral,  and  precipitates  the  earthy 
phosphates  on  heating,  and  sometimes  on  standing.  The 
diminution  of  the  acidity  of  the  urine  secreted  during  gastric 
digestion  is  a  rough  measure  of  the  increase  of  the  hydro- 
chloric acidity  of  the  gastric  juice. 

The  bowels  are  constipated,  but  in  spite  of  the  excessive 
acidity  of  the  chyme  the  starches  and  fats  may  not  exist  in 
abnormal  quantity  in  the  stools,  and  the  balance  of  nutrition 
may  be  maintained.  The  weight,  and  the  strength,  and  the 
color  may  be  those  of  health,  but  moderate  emaciation  is 
frequent.  The  appetite  is  preserved,  or  it  ma\'  be  very  sharp, 
and  a  meal  taken  later  than  usual  will  be  preceded  by  hunger. 

Diagnosis. — The  diagnosis  should  present  little  difficulty  if 
the  examination  has  been  complete.  The  following  diagnostic 
signs  should  be  clearly  fixed  in  the  mind  : 

The  general  health,  the  weight,  and  the  strength  are  well 
preserved  if  the  diet  has  not  been  restricted.  The  food  being 
well  digested,  and  not  destroyed  by  fermentation,  nor  lost  by 
vomiting  or  by  diarrhea,  there  is  no  reason  why  the  balance 
of  nutrition  should  not  be  maintained.  The  good  appetite 
will  secure  the  ingestion  of  a  sufficient  quantity  of  food,  un- 
less the  diet  be  reduced  on  account  of  fear  of  pain  or  in  con- 
sequence of  improper  treatment. 

The  symptoms  are  all  digestive  and  gastric.  During  the 
period  of  repose  of  the  stomach  there  is  no  complaint.  The 
symptoms  do  not  begin  immediately  after  the  ingestion  of 
food,  but  develop  in  relation  with  the  evolution  of  secre- 
tion, and  are  most  intense  during  the  period  of  greatest  free 
hydrochloric  acidity.  The  severity  of  the  attack  is  dependent 
upon  the  action  of  the  food,  upon  the  power  which  it  has  of 
combining  the  secreted  HCl,  upon  the  activity  of  hydrochloric 
secretion,  and  upon  the  irritabilit}'  of  the  nervous  system  at 
the  moment  when  the  food  i* eaten.  The  pain  is  calmed  by 
albuminous  food  and  alkalies  ;  it  is  uninfluenced  or  made 
worse  by  electricity,  and  disappears  with  the  evacuation  of 
the  stomach.  The  symptoms  may  appear  only  after  the  chief 
meal.  A  glass  of  milk  taken  alone  is  usually  rapidly  and 
comfortably  digested. 


THE   DYNAMIC  AFFECTIONS   OF  SECRETION.  29 1 

The  objective  signs  are  even  more  characteristic.  The 
stomach  is  normal  in  position  and  in  size,  the  motor  function 
(unless  there  is  spasm  of  the  pylorus)  and  absorption  are 
normal,  and  there  are  no  bacteriological  nor  anatomical  signs. 
The  resting  stomach  is  empty.  During  digestion  an  exces- 
sively acid  gastric  juice,  rich  in  both  ferments,  is  secreted. 

Differential  Diagnosis. — The  differential  diagnosis,  in  spite 
of  the  clear-cut  features  of  the  disease,  may  present  some 
difficulties,  and  in  some  cases  only  a  probable  decision  can  be 
made. 

Myasthenia  with  supersecretion  presents  a  very  similar 
group  of  symptoms,  which  are  digestive,  increase  with  the 
evolution  of  digestion,  and  may  attain  their  climax  with  par- 
oxysms of  pain.  The  objective  signs  can  alone  differentiate 
the  two  diseases.  These  signs  are  those  of  myasthenia,  which 
are  never  present  in  hyperchlorhydria.  After  the  test-breakfast 
the  quantity  of  contents  is  normal  in  hyperchlorhydria  ;  the 
emulsion-meal  of  Mathieu  shows  that  the  contents  are  evacu- 
ated into  the  intestines  with  normal  rapidity ;  after  a  Leube- 
Riegel  or  a  Germain  See  meal  the  evacuation  of  the  stomach 
is  not  delayed,  and  digestive  products  do  not  accumulate  in  the 
stomach.  In  myasthenia  there  is  splashing  when  a  glass  of 
water  has  been  given  on  an  empty  stomach,  after  the  normal 
interval  has  elapsed  ;  and  the  stomach  during  digestion  is  often 
flabby.  Two  glasses  of  water  taken  on  an  empty  stomach  are 
not  evacuated  within  one  and  one-half  hours,  for  myasthenia  is 
a  "  dyspepsia  of  liquids."  The  motor  insufficiency  revealed  by 
the  water-test  is  the  most  characteristic  sign,  and  the  super- 
secretion  increases  or  decreases  with  the  increase  or  decrease 
of  the  myasthenia.  The  free  HCl  may  appear  early  in  myas- 
thenia, but  the  acme  of  hydrochloric  acidity  is  postponed,  and 
the  decline  of  secretion  is  delayed.  If  the  myasthenia  is  asso- 
ciated with  retention,  the  differentiation  is  easy.  The  digestive 
subjective  symptoms,  which  in  myasthenia  with  stagnation 
extend  over  a  longer  period  than  in  hyperchlorhydria,  be- 
come confused  with  the  retention  symptoms  occurring  during 
the  period  of  normal  gastric  repose.  The  retention  of  food 
excludes  hyperchlorhydria,  in  which  affection  there  is  never 
found  in  the  stomach  in  the  early  morning  before  breakfast 
either  retained  food  or  accumulated  digestive  products,  or 
an  excessive  quantity  of  gastric  juice. 

The  displacements  of  the  stomach  may  manifest  the  same 
subjective  symptoms — uneasiness,  acid  eructations,  heartburn, 
and  gastric  pain  two  to  four  hours  after  meals.  The  pain, 
however,   is  peristaltic,  and  is   due   to  the  violent   efforts  to 


292  DISEASES  OF  THE  STOMACH. 

overcome  the  duodenal  traction-produced  obstruction,  and 
these  strong  contractions  may  be  felt  by  the  palpating  hand 
(they  are  sometimes  also  visible)  over  an  abnormal  area,  and 
reveal  the  displacement  of  the  stomach.  The  pain  is  not 
relieved  by  albuminous  food,  and  milk  may  be  badly  borne. 
The  physical  and  functional  signs  make  the  differentiation 
clear.  Intlation  reveals  the  displacement  of  the  stomach, 
which  is  often  associated  with  a  deformed  liver,  a  movable 
right  kidney,  and  prolapse  of  the  transverse  colon.  The 
chemical  signs,  in  case  the  displacement  is  complicated  by 
glandular  gastritis,  or  by  supersecretion  produced  by  irrita- 
tion of  the  stagnant  contents,  are  never  the  same  as  are  found 
in  hyperchlorhydria.  The  water-test  will  exclude  or  reveal 
the  myasthenia,  but  we  would  emphasize  the  fact  that  the 
displaced  stomach  is  subject  to  the  same  disorders  and  dis- 
eases as  the  stomach  in  its  normal  position.  The  effect  of  a 
properly  fitting  abdominal  belt  and  of  myasthenic  medication 
may  be  suggestive.  But  in  many  of  the  cases  of  gastroptosis 
an  excessively  rich  gastric  juice  is  not  secreted,  and  there  is 
stagnation,  often  fermentation,  and  accumulation  of  digestive 
products  in  the  stomach.  In  hyperchlorh\'dria  there  is  never 
displacement  (unless  the  displacement  be  a  primary  or  acci- 
dental association),  nor  motor  insufficiency,  nor  fermentation, 
and  during  the  digestive  period  secretion  is  always  exces- 
sively rich,  but  is  never  abnormally  large  in  quantity. 

Hyperchlorhydria  may  easily  be  confounded  with  ulcer. 
A  hemorrhage,  large  or  small  (not  due  to  retching),  would 
exclude  the  functional  trouble.  The  subjective  and  the 
functional  signs  may  be  almost  the  same  in  the  two  diseases, 
but  hydrochloric  acid  is  not  ahvaj's  in  e.xcess  in  the  gastric 
contents  of  ulcer.  The  pain  of  ulcer  is  not  relieved  by  tak- 
ing albuminous  food  ;  it  is  not  purely  digestive,  is  increased 
by  movement,  may  be  relieved  by  rest  in  a  particular  position, 
and  does  not  always  develop  in  relation  with  the  evolution  of 
secretion  and  of  digestion.  The  exquisitely  painful  epigas- 
tric and  dorsal  points  of  ulcer  may  exist  even  when  the 
stomach  is  empty.  Hyperchlorhydria  is  a  predisposing 
cause  of  ulcer  ;  and  when  doubt  exists,  an  ulcer  cure  should 
be  prescribed. 

Hypersthenic  gastritis  resembles  hyperchlorhydria  even 
more  closely  than  does  ulcer,  but  the  differentiation  is  never 
diflficult.  A  large  number  of  the  cases  of  chronic  hyper- 
sthenic gastritis,  primary  and  .secondary,  are  easily  excluded 
by  the  associated  stagnation,  displacement,  fermentation,  or 
supersecretion.     But  a  notable  percentage  of  the    cases   of 


THE   DYNAMIC   AFFECTIONS  OF  SECKETJON.  293 

primary  hypersthenic  gastritis,  particularly  in  the  early  stage 
of  the  disease,  are  expressed  by  the  objective  and  the  func- 
tional signs  of  digestive  secretory  irritation.  The  gastritis  is 
more  directly  traceable  to  dietetic  errors  and  to  alcoholism, 
an  adequate  cause  for  its  existence  being  thus  found.  The 
contents,  after  the  test-meal,  contain  a  large  quantity  of 
mucus,  cell  nuclei,  exfoliated  and  unseparated  epithelium, 
chief  and  border  cells  and  blood;  and  misfortune  may  conclu- 
sively reveal  the  anatomical  nature  of  the  disease  in  a  piece 
of  scraped-off  mucous  membrane.  Hyperchlorhydria  may 
be  intermittent  in  its  manifestations,  and  in  closer  relation 
with  the  state  of  the  nervous  system  than  with  the  alimenta- 
tion. Some  of  the  enumerated  differential  signs  differ  only 
in  degree,  and  not  in  kind,  and  it  would  be  impossible  to  say 
where  hyperchlorhydria  ends  and  hypersthenic  gastritis 
begins,  if  it  were  not  for  the  excessive  mucus  and  the  dis- 
tinctive anatomical  signs  of  gastritis. 

Treatment. — Both  on  account  of  the  suffering  which  it 
produces  and  on  account  of  the  serious  diseases  for  which  it 
prepares  the  way,  hyperchlorhydria  should  receive  careful 
treatment. 

The  two  ruling  principles  of  its  treatment  are  sedation  and 
the  improvement  of  the  condition  of  the  nervous  system. 
The  irritable  nervous  system  demands  rest,  which  must  be 
obtained  at  any  cost.  It  may  be  sufficient  to  lighten  the 
daily  burdens,  to  correct  excesses,  or  to  send  the  patient 
away  from  home  cares  to  lead  a  pleasant  outdoor  life.  In 
severe  cases  it  may  be  necessary  to  prescribe  a  rest-cure,  for 
a  few  weeks,  in  bed. 

Electricity,  which  does  not  relieve  the  pain,  should  be  used 
with  care ;  and  only  sedative  anodal  gastric  or  epigastric 
galvanization  of  the  empty  stomach  should  be  employed. 
Hydrotherapy  should  be  used  to  tone  the  nervous  system, 
and  the  hot  compress  during  digestion  exerts  a  soothing  in- 
fluence on  the  stomach.  Penzoldt  recommends  lavage  in  the 
evening,  sometimes  daily,  sometimes  less  frequently,  but  we 
rarely  employ  stomach  washing  in  this  affection. 

The  diet  is  indicated  by  the  functional  signs,  and  should 
be  chemically  and  mechanically  non-irritating,  leaving  as 
little  HCl  uncombined  as  possible.  The  albumins  of  the 
various  foods  do  not  possess  the  same  acid-combining  equiva- 
lents, and  the  albumin  digestive  products  combine  more  HCl 
as  the  digestive  transformation  proceeds.  Thus,  antipeptone 
combines,  in  percentage,  twice  as  much  HCl  as  hetero-albu- 
mose,  and   hetero-albumose  combines  double  the  quantity  of 


294  DISEASES  OF  THE  STOMACH. 

HCl  that  is  combined  b\'  proto-albumose.  As  a  result  of 
experiments,  we  find  that  lOOi^m.  of  the  following  foods,  when 
cooked,  require,  at  '})'j°  C,  the  addition  of  about  the  following 
quantities  of  a  three  per  thousand  solution  of  HCl  before 
the  HCl  remains  free:  Lean  beef,  650  c.c  ;  veal,  710  c.c. ; 
mutton,  630  c.c;  milk,  120  c.c;  roil,  105  c.c;  wholewheat 
preparations,  2Cxd  c.c;  rice,  230  c.c;  chicken,  640  c.c;  fish, 
250  c.c;  cheese,  300  to  800  c.c;  lean  ham,  720  c.c;  eggs, 
400  c.c.  The  physiological  action  of  the  various  foods  on 
secretion,  in  addition  to  their  acid-combining  power,  should 
guide  in  the  selection  of  the  diet.  The  diet  must  be  largely 
albuminous,  and  must  be  neither  physically  nor  chemically 
e.Kcitant.  Milk,  lean  and  fine-fibered  fish,  lean  meats  reduced 
to  pulp,  the  soft  part  of  small  and  fresh  o\'sters,  plainly 
cooked  game,  slightly  cooked  eggs,  are  all  suitable  articles. 
The  cereals, — rice,  wheat,  oatmeal, — very  thoroughly  cooked 
and  fresh,  possess  a  high  acid-combining  power,  and  may  be 
added  to  the  diet  list ;  but  it  should  be  remembered  that  the 
cereals  and  bread  contain  starch  also,  and  the  starchy  foods 
e.Kcite  the  secretion  of  more  HCl  than  they  can  combine. 
Vegetables  and  fruits  must  be  avoided,  and  only  enough  fat 
in  the  form  of  fresh  (unsalted)  butter  or  cream  to  supply  the 
needs  of  nutrition  should  be  permitted.  Spices,  condiments, 
acids,  oils,  and  alcoholic  drinks  should  be  absolutely  prohib- 
ited. Sweets  increase  the  quantity  but  diminish  the  acidity 
of  the  gastric  juice,  and  in  moderate  quantity  are  beneficial 
in  hyperchlorhydria.  Milk,  an  alkaline  mineral  water,  or 
plain  water  are  the  beet  drinks.  Very  weak  tea  and  coffee 
may  sometimes  be  permitted,  but  cocoa  and  "  vigor  choco- 
late "  (Hauswaldt)  are  better.  Dry  food  is  \txy  injurious, 
and  about  two  glasses  of  fluid  may  be  permitted  with  each 
meal.  An  hour's  repose  after  each  meal  is  obligatory.  It  is 
best,  in  our  opinion,  to  permit  only  three  meals  a  day. 

In  the  treatment  of  hyperchlorhydria  the  alkalies  have 
long  held  a  prominent  place.  Bicarbonate  of  soda  and  cal- 
cined magnesia  may  be  given  during  the  period  of  free  acidity 
in  repeated  doses,  as  recommended  in  the  chapter  on  Chemi- 
cal Treatment.  If  the  pain  be  very  severe,  belladonna  (J^  to 
■5L.  of  a  gr.  ext.)  and  codein  {\  of  a  gr.),  or  opium  (y'-jj  of  a  gr. 
aq.  ext.),  may  be  given  before  each  meal.  Our  favorite  pre- 
scription is  the  extract  of  belladonna  combined  with  two 
grs.  of  extract  of  coca  before  each  meal.  Opium,  if  it  is 
ever  advisable,  should  be  given  in  full  doses,  as  small  doses 
of  opium  excite  secretion  and  the  nervous  system.  Cannabis 
indica   rarely   proves  useful,  and    the   bromids   do  no  good. 


THE  DYNAMIC  AFFECTIONS  OF  SECRETION.  295 

We  sometimes  use  nitrate  of  silver  (by  mouth  or  by  means  of 
the  intragastric  douche),  and  large  doses  of  bismuth,  em- 
ployed as  does  Fleiner  in  the  treatment  of  ulcer,  are  some- 
times beneficial.  Under  the  influence  of  this  treatment  the 
constipation  and  the  pain  may  rapidly  be  relieved.  If  the 
constipation  requires  additional  attention,  an  injection  (to 
which  a  teaspoonful  of  glycerin  may  be  added)  should  be  em- 
ployed, or  gluten  suppositories,  or  glycerin  suppositories,  or 
anodal  sedative  galvanization  of  the  colon  may  be  tried. 
Purgatives  repeatedly  given  by  the  mouth  destroy  any  good 
effects  derived  from  the  other  remedies.  The  stomach  must 
be  consistently  and  thoroughly  protected  against  all  forms  of 
irritation. 

(B)   DIGESTIVE  HYPERCHYLIA  GASTRICA. 

Supersecretion  in  response  to  the  physiological  action  of 
food  is  a  distinct  dynamic  affection  of  the  stomach.  The 
gastric  juice,  as  a  rule,  is  abnormally  rich  in  acid  and  fer- 
ments ;  but  it  may  be  normal  in  quality,  and,  exceptionally, 
it  contains  a  diminished  percentage  of  hydrochloric  acid  and 
ferments.  There  is  no  anatomical  lesion  of  the  mucosa,  and 
the  motor  function  is  normal.  Digestion  is  prolonged  because 
secretion  is  excessive  in  quantity. 

Etiology. — The  causes  of  digestive  hyperchylia  are  the  same 
as  those  which  produce  hyperchlorhydria,  and  no  complete 
explanation  has  yet  been  given  of  the  genesis  of  either  affec- 
tion. The  underlying  condition  may  be  a  direct  or  indirect 
disturbance  of  the  nerve-centers  which  control  secretion,  or 
excessive  vital  activity  of  the  chief  and  border  cells,  or  an 
impure  blood,  or  a  vasomotor  disturbance.  These  patients 
are  most  frequently  neurotics,  or  neurasthenics,  or  young 
persons  guilty  of  excesses  which,  directly  or  indirectly,  affect 
the  brain,  the  central  nervous  system,  or  the  abdominal  sym- 
pathetic. 

Clinical  Description. — Digestive  hyperchylia  may  be  a 
latent  disease,  or  the  patient  may  intermittently  pass  a  number 
of  comfortable  days.  Most  frequently  the  symptoms  recur 
daily,  sometimes  after  each  meal,  or,  as  the  rule,  only  after 
the  second  and  third  meals  of  the  day,  the  patient  having  an 
attack  of  eructations,  belching,  heartburn,  pain,  sometimes 
vomiting,  and  headache  during  the  course  of  the  afternoon 
and  another  in  the  evening.  Vomiting  and  headache  are  more 
frequent  than  in  hyperchlorhydria,  the  pain  is  often  severe  and 
spasmodic,  and  all  the  symptoms  occur  in  relation  with  the 


296  DISEASES  OF  THE   STOMACH. 

evolution  of  secretion  and  digestion.  Tiie  foods  which  excite 
secretion  most  and  remain  long  in  the  stomach  produce  the 
greatest  discomfort.  The  appetite  is  usualh'  good,  and  thirst 
is  excessive.  Emaciation  is  more  frequent  than  in  hyper- 
chlorhydria,  and  the  digestive  and  motor  functions  of  the 
intestines  are  disturbed  by  the  large  quantity  of  chyme,  which 
may  be  superacid  and  fermenting. 

More  characteristic  than  the  clinical  history  are  the  phj-sical, 
functional,  and  bacteriological  signs.  The  abdomen  is  tender 
over  the  region  of  the  stomach.  Splashing  and  gurgling 
(gliding  method)  can  be  produced  at  a  time  after  a  meal  when 
the  normal  stomach  would  be  empty.  One  hour  after  the 
test-breakfast  the  stomach  contains  more  than  150  c.c.  of 
ch\'me ;  two  hours  after  the  test-meal  of  See  more  than  175 
c.c.  of  contents  can  be  expressed  or  estimated  b}'  the  dilution 
and  total  acidity  method  ;  after  the  Riegel  dinner  more  than 
200  c.c.  may  be  obtained.  Consequently,  the  quantity  of  the 
contents  is  abnormally  large.  The  specific  gravity  of  the  fil- 
trates of  the  contents  after  the  test-meals  is  below  normal : 
After  the  test-breakfast,  below  loio;  after  the  test-meal  of 
See,  below  1015;  and  after  the  test-dinner  of  Riegel,  below 
I020-  The  ferments  are  present  in  normal  quantity  or  in 
excess.  There  mayor  may  not  be  hydrochloric  superacidity, 
and  the  quantity  of  combined  HCl  is  frequently  diminished. 
The  albumins  are  well  digested,  but  starch  digestion  is 
decreased,  Lugol's  solution  producing  a  blue  or  purplish 
color.  Fehling's  test  for  sugar  is  negative,  or  a  small  quan- 
tity of  the  copper  may  be  reduced.  There  is  never  an  abnor- 
mal quantity  of  gastric  mucus.  The  evacuation  of  the  chyme 
is  always  delayed,  digestion  being  prolonged  in  proportion  to 
the  supersecretion.  The  prolongation  of  digestion  is  propor- 
tionately greater  after  Riegel's  test-dinner  than  after  the  test- 
breakfast.  When  the  patient  eats  his  customary  three  daily 
meals,  the  stomach  may  or  may  not  succeed  in  emptying 
itself  between  the  meals.  Two  glasses  of  water  are  evacuated 
within  the  normal  period.  Secretion  is  inactive  while  the 
stomach  is  empty.  There  is  no  stagnation  of  solids  or  of 
liquids,  but  the  physical  properties  of  the  contents  are  such 
as  would  be  produced  by  supersecretion  during  the  evolution 
of  digestion.  The  quality  of  secretion  may  be  estimated  and 
supersecretion  recognized  by  the  emulsion-meal  of  Mathieu 
or  the  authors'  meal  for  testing  absorption. 

The  prolongation  of  digestion   favors  the  development  of 
fermentation.     The   most   common   form   of  fermentation    in 


THE   DYNAMIC  AFFECTIONS  OF  SECRETION.  297 

digestive  hyperchylia  is  acetic  fermentation.  The  urine 
changes  are  of  the  same  nature  but  more  pronounced  than 
its  changes  in  hyperchlorhydria. 

Diagnosis. — The  chnical  history  of  hyperchylia  gastrica 
is  not  distinctive,  but  the  subjective  symptoms  possess  some 
diagnostic  features.  The  symptoms  all  occur  during  the 
period  of  digestion,  although  the  duration  of  this  period  is 
abnormally  long.  While  the  stomach  contains  no  food,  there 
are  no  subjective  symptoms  and  secretion  ceases.  The 
symptoms  are  intensified  by  large  meals,  and  by  foods  which 
remain  long  in  the  stomach  and  which  excite  free  secretion. 
Albuminous  food  may  temporarily  diminish  the  pain,  but  the 
attack  is  prolonged  by  eating  food.  The  functional  signs  are 
characteristic.  The  contents  are  too  large  in  quantity,  of 
abnormally  low  specific  gravity,  usually  rich  in  acid  and 
ferments.  Digestion  is  prolonged  without  motor  insufficiency, 
and  mucus  is  not  secreted  in  excess.  Fermentation  may  or 
may  not  B^e  present. 

Differential  Diagnosis. — Hyperchylia  gastrica  closely  re- 
sembles hyperchlorhydria  in  many  respects,  and  after  what 
has  already  been  said  its  differentiation  from  ulcer  and  chronic 
gastritis  may  be  omitted.  Digestive  hyperchylia  is  most 
frequently  confounded  with  hyperchlorhydria,  myasthenia, 
and  pyloric  obstruction.  The  functional  signs,  the  prolon- 
gation of  digestion,  the  relation  of  the  symptoms  to  the 
quantity  and  quality  of  the  food,  and  sometimes  the  occur- 
rence of  fermentation  distinguish  it  readily  from  hyperchlor- 
hydria. 

In  both  myasthenia  and  digestive  hyperchylia  the  period 
of  digestion  is  prolonged — in  the  one,  on  account  of  motor 
insufficiency;  in  the  other,  on  account  of  supersecretion.  In 
myasthenia  the  stomach  is  flabby,  easily  distensible,  slightly 
retractile,  and  the  line  representing  the  acidity  of  the  con- 
tents during  the  evolution  of  digestion  is  irregular.  In 
digestive  hyperchylia  the  stomach  possesses  its  normal 
tonicity,  retracts  when  it  is  empty,  and  the  evolution  of 
digestion  is  abnormal  but  regular.  One  and  one-half  hours 
after  the  administration  of  two  glasses  of  water  the  stomach 
is  empty  in  hyperchylia,  but  in  myasthenia  it  contains  a 
quantity  of  water  proportionate  to  the  motor  insufficiency. 
The  quantity  of  water  which  it  contains  may  be  exactly  de- 
termined by  introducing  100  c.c.  of  a  one  per  cent,  solution 
of  sugar  into  the  stomach,  mixing  it  thoroughly  with  the 
contents,  and  subtracting  100  from  the  result  obtained  by 
dividing  lOO  by  the  reduced  percentage   of  sugar   in    the  ex- 


298  DISEASES  OF  THE  STOMACH. 

pressed  dilution.  In  myasthenia  tlie  delay  in  the  evacuation 
of  the  contents  is  proportionate  to  the  fluidity  and  the  quan- 
tity of  the  food  and  to  its  action  on  the  motor  function.  In 
hyperchyUa  the  stomach  empties  itself  most  rapidly  when 
the  diet  is  fluid  and  e.Kcites  little  secretion.  By  means  of  our 
meal  for  testing  absorption,  or  of  the  emulsion-meal  of 
Mathieu,  the  portion  of  the  total  contents  which  is  due  to 
secretion  can  be  estimated.  This  portion  is  abnormally 
large  in  supersecretion,  and  normal  in  quantity  in  myas- 
thenia. Expression  of  the  contents  is  easy  in  hyperchylia; 
in  myasthenia  it  is  always  difficult  and  incomplete. 

In  the  absence  of  a  palpable  tumor  of  the  pylorus,  or  of 
the  history  or  signs  of  a  disease  which  is  liable  to  produce 
obstruction  of  the  pylorus  or  of  the  duodenum,  the  differen- 
tiation of  hyperchylia  and  obstruction  may  require  close 
study.  The  evolution  and  the  grouping  of  the  symptoms 
may  be  distinctive.  Obstruction  is  persistent,  obstinate,  often 
progressive,  and  obstructive  stagnation  is  a  stagnation  of 
solid  and  coarse  food.  Hyperchylia  yields  rapidly  to  appro- 
priate treatment,  and  the  prolonged  digestion  is  due  to  the 
continuous  dilution  of  the  contents  by  supersecretion.  The 
evolution  of  digestion  is  irregular  in  obstruction  ;  but  it  is 
regular,  although  abnormal,  in  hyperchylia.  The  functional 
signs  may  be  similar  or  they  may  be  distinctive  of  the  one  or 
the  other  disease.  Two  glasses  of  water  are  evacuated  within 
the  normal  period  in  both  diseases,  unless  the  obstruction  is 
so  great  as  to  produce  the  severe  form  of  stagnation  ;  but  a 
glass  of  a  ten  per  cent,  solution  of  sugar  is  evacuated  much 
earlier  in  obstruction  than  in  hyperchylia  gastrica. 

Treatment. — The  treatment  of  digestive  hyperchylia  gas- 
trica consists  in  the  removal  of  the  cause,  when  this  can  be 
accomplished,  and  in  the  employment  of  remedies  to  tone 
and  quiet  the  nervous  system  and  to  improve  the  general 
health.  Rest,  open-air  exercise,  electricity,  massage,  and 
appropriate  baths  are  usually  beneficial.  Bismuth,  bella- 
donna, and  ergot  are  the  drugs  which  we  have  found  to  exert 
a  controlling  influence  on  the  supersecretion.  The  bismuth 
should  be  given  in  a  single  large  dose  (one  dram)  before 
breakfast,  and  the  belladonna  and  ergot  may  be  ordered  in 
small  doses  before  each  meal. 

But  the  special  treatment  of  digestive  hyperchylia  gastrica 
is  dietetic.  No  foods  should  be  permitted  which  greatly 
excite  secretion  and  which  remain  a  long  time  in  the  stomach. 
Sweets  should  be  prohibited,  and  the  red  meats  increase  the 
supersecretion.     Condiments,  tea,  coffee,  and  alcoholic  drinks 


THE   DYNAMIC  AFFECTIONS  OF  SECRETION.  299 

are  injurious.  The  meals  should  be  small,  chiefly  fluid,  and 
separated  by  intervals  long  enough  to  allow  the  complete 
evacuation  of  the  stomach.  Milk,  cream,  cereals,  eggs,  calf's 
brain,  young  chicken,  squab,  green  vegetables  thoroughly 
cooked  and  passed  through  a  sieve  to  insure  fine  division, 
are  appropriate  articles  of  food.  The  diet  of  hyperchlorhydria, 
which  is  chiefly  albuminous,  is  badly  borne  and  injurious  in 
hyperchylia.  Exclusive  rectal  feeding  is  rapidly  curative,  and 
it  should  always  be  employed  for  a  few  days  in  the  beginning 
of  the  treatment  of  the  severe  cases. 


(C)   PAROXYSMAL   HYPERCHYLIA  GASTRICA. 

Paroxysmal  hyperchylia  gastrica — gastroxynsis  (Ross- 
bach),  gastroxia  (Lepine),  intermittent  or  periodical  gastro- 
succorrhea — is  a  dynamic  affection  of  the  stomach  character- 
ized by  severe  headache,  by  vasomotor  disturbances,  and  by 
the  supersecretion  of  an  excessively  acid  gastric  juice,  rich 
in  ferments;  it  recurs  in  paroxysms,  separated  by  intervals 
of  perfect  health.  It  is  a  cerebrogastric  trouble,  due  to  the 
reaction  of  an  irritable  and  exhausted  brain  on  the  solar 
plexus  (Leven);  or  to  excessive  secretion  excited  by  an  irrita- 
ble cortex,  the  wide-spread  vasomotor  disturbances  proceed- 
ing from  the  gastric  mucous  membrane  (Rossbach);  or  it  is 
due  to  a  primary  disturbance  of  the  vasomotor  center  in  the 
medulla,  of  which  the  gastric  and  cerebral  symptoms  are 
expressions  (Rosenthal).  The  affection  is  very  closely  re- 
lated to  migraine,  of  which  it  is  probably  a  form. 

Etiology. — Gastroxynsis  is  a  disease  of  school-children,  of 
students,  and  of  brain-workers,  and  appears  to  be  almost 
exclusively  met  with  in  the  male  sex.  The  attacks  occur 
periodically,  being  excited  by  mental  overwork.  Abuse  of 
tobacco  is  said  to  be  another  cause.  The  disease  is  some- 
times met  with  in  persons  who  can  not  be  accused  of  mental 
overwork,  and  it  may  be  excited  by  intestinal  auto-intoxica- 
tion and  by  biliary  and  renal  colic.  It  occurs  as  a  symptom 
of  sclerotic  bulbar  lesions. 

Clinical  Description. — The  attacks  begin  suddenly,  without 
prodromal  symptoms,  unexpectedly,  either  during  digestion 
or  during  the  period  of  gastric  repose,  but  most  frequently 
during  the  second  half  of  the  night,  with  severe,  colicky  gastric 
pains  which  may  or  may  not  be  accompanied  by  headache. 
The  pain  may  radiate  over  the  abdomen  and  into  the  back  and 
shoulders,  and  be  so  severe  as  to  produce  collapse.     Vomiting 


300  DISEASES  OF  THE  STOMACH. 

soon  follows,  but  it  affords  only  partial  and  temporary  relief, 
and  recurs  again  and  again  after  short  intervals.  The  vomit 
consists  of  the  accidental  contents  of  the  stomach  and  of  a 
gastric  juice  rich  in  h\-drochloric  acid  and  ferments  and 
tinged  green  with  bile.  If  food  be  in  the  stomach  when  the 
attack  begins,  the  vomit  is  strongly  acid,  the  acidity  being  due 
to  an  excess  of  free  and  a  large  quantity  of  combined  hydro- 
chloric acid.  After  the  stomach  is  emptied  secretion  con- 
tinues; and  the  vomit  consists  of  a  greenish  fluid  of  a  total 
acidity  of  20  to  40  and  a  specific  gravity  of  about  IO06, 
and  containing  the  ferments  of  the  stomach.  The  acidity 
is  due  almost  entirely  to  acid  phosphates  (6  to  12)  and  to 
free  hydrochloric  acid.  There  is  no  noteworthy  increase 
of  gastric  mucus  and  no  blood,  but  a  few  cell  nuclei  are 
present.  The  quantity  of  fluid  vomited  is  largely  in  excess 
of  what  has  been  swallowed.  Secretion  is  active  and  con- 
tinuous. Headache  may  be  the  predominant  symptom,  and 
it  is  sometimes  agonizing,  or  it  may  be  but  slight.  Appetite 
is  lost  and  the  patient  complains  of  great  thirst.  During 
the  interval  betweert  the  attacks  the  well-nourished  patient 
experiences  no  discomfort  during  digestion,  the  appetite  is 
good,  and  the  functional  signs  are  normal. 

Diagnosis. — Paroxysmal  hj'perchylia  gastrica  is  character- 
ized by  intermittent  painful  attacks  of  supersecretion  and 
vomiting,  separated  by  intervals  of  normal  gastric  digestion. 
Locomotor  ataxia  and  multiple  sclerosis  maybe  accompanied 
by  similar  paroxysms,  and  in  every  case  the  signs  of  these 
diseases  should  be  sought.  Paroxysmal  supersecretion  may 
be  the  initial  symptom  of  tabes  dorsalis. 

Treatment. — The  patient  should  be  put  to  bed  in  a  darkened 
room,  and  hot  water  administered.  If  given  in  the  beginning 
of  the  attack,  the  hot  water  may  abort  it,  and  later  it  will 
excite  profuse  vomiting  and  afford  relief  (Rossbach).  Phena- 
cetin,  antipyrin,  or  antifebrin  may  also  be  administered. 
Caffein  may  give  relief  if  administered  early  in  the  attack. 
The  Winternitz  compress  is  beneficial.  The  best  treatment 
in  the  beginning  of  the  attack  is  a  thorough  stomach  wash- 
ing, followed  by  a  purgative  dose  of  calomel,  and  by  mor- 
phin  and  atropin  hypodermically.  During  the  attack  food 
should  not  be  given  by  mouth,  but  the  patient  should  be 
nourished  exclusively  by  enemata. 

The  preventive  treatment  consists  in  the  avoidance  of  men- 
tal fatigue  and  of  intestinal  stagnation  and  decomposition, 
in  digestive  hygiene,  and  in  attention  to  the  general  health. 
Errors  of  refraction  should  be  corrected  h\  glasses. 


THE  DYNAMIC  AFFECTIONS    OF  SECRETION.  3OI 


2.  ADENASTHENIA    GASTRICA. 

A  dynamic  affection  of  the  stomach,  characterized  by  a 
diminished  and  a  poor  secretion  without  an  anatomical  lesion 
of  the  mucous  membrane,  is  known  as  adenasthenia  gastrica 
(subacidity,  anacidity,  hypochlorhydria,  hypochylia). 

Etiology. — The  disease  is  less  frequent  than  adenohyper- 
sthenia  gastrica,  and  may  be  met  with  as  a  particular  form  of 
neurasthenia  gastrica  and  in  hysteria  and  the  psychoses. 
But  the  trouble  may  develop  in  those  who  are  neither  neuro- 
pathic nor  neurasthenic,  and  may  be  a  consequence  of  railway 
shock,  of  fright,  of  sorrow,  of  depressing  moral  influences, 
or  of  chronic  subnutrition.  It  is  sometimes  found  in  the 
severe  anemias  and  in  chlorosis,  and  is  a  symptom  of  many 
of  the  acute  febrile  diseases.  Adenasthenia  gastrica  predis- 
poses to  intestinal  diseases. 

Clinical  Description. — Gastric  subjective  symptoms  may  be 
entirely  wanting  or  may  consist  in  slight  digestive  discomfort. 
The  appetite  is  often  poor,  but  if  the  intestines  are  healthy 
and  enough  food  is  taken  the  general  nutrition  is  well 
maintained.  The  urine  is  often  highly  acid,  the  diminution 
of  its  acidity  during  digestion  does  not  occur,  and  uric  acid 
frequently  precipitates  after  the  urine  stands  for  a  few  hours. 
There  may  or  may  not  be  diarrhea,  which  is  as  frequent  in 
adenasthenia  as  constipation  is  in  adenohypersthenia  gastrica. 

The  patient  feels  unfitted  for  work,  and  no  adequate  cause 
can  be  found  for  the  mental  depression.  It  is  usually  difficult 
to  persuade  the  adenasthenic  that  there  is  nothing  serious 
the  matter,  the  thoughts  and  feelings,  it  would  seem,  taking 
all  their  color  from  the  depressed  function  of  the  stomach. 

The  functional  signs  are  the  distinctive  characteristics  of 
the  disease.  The  filtrate  of  the  contents  obtained  after  the 
test-breakfast  contains  no  free  HCl  (H),  the  albuminoid 
affinities  for  acid  are  not  satisfied,  and  in  some  cases  the 
combined  hydrochloric  acid  (C)  is  present  in  mere  traces  or 
is  altogether  wanting.  The  ferments  may  be  present  in  pro- 
portionately greater  quantity,  but,  as  a  rule,  the  pepsin  is 
diminished  in  proportion  to  the  diminution  of  the  total  HCl, 
but  not  of  the  free  HCl  alone.  If  hydrochloric  acid  be 
administered  ten  minutes  before  the  expression  of  the  test- 
breakfast  contents,  both  tube  peptonization  and  milk  curdling 
are  sometimes  as  active  as  in  health,  for  the  mother  substances 
of  the  ferments  are  present  in  greater  quantity  than  are  the 
converted  ferments.     Another  characteristic  is  the  influence 


302  DISEASES  OF  THE  STOMACH. 

of  electricity.  Cathodal  dorsogastric  galvanization  for  ten 
minutes,  with  a  current  of  five  to  ten  milliamperes  and  a  cur- 
rent density  oi  4^,  during  the  second  half  hour  of  the  diges- 
tion of  the  test-breakfast,  improves,  or  even  removes,  the 
secretorj'  depression.  In  the  gastric  contents  after  the  test- 
breakfast,  or  after  the  test-meal  of  Germain  See,  there  is  only 
a  moderate  quantity  of  syntonin  and  propeptones,  a  large 
quantitt'  of  the  albumin  remaining  undissoh-ed.  The  acidu- 
lated tube  pepsin  tests  give  a  digestive  percentage  less  than 
normal,  and  the  dilution  is  always  less  active  than  the  undiluted 
test.  There  is  no  motor  insufficiency  in  spite  of  the  absence 
of  the  motor  stimulation  exerted  by  hydrochloric  acid,  the 
test  contents  being  less  liquid  than  normal.  There  is  little 
mucus,  no  excess  of  formed  elements,  and  no  fermentation, 
except,  irregularly,  there  may  be  a  strong  odor  of  butyric 
acid.  Starch  digestion  is  greater  than  in  the  normal  stomach. 
The  specific  gravity  of  the  contents  is  abnormally  high,  and 
the  total  quantity  of  secretion  is  frequenth'  diminished. 

Differential  Diagnosis. — The  functional  signs,  the  genesis, 
the  vague  subjecti\'e  s\'mptoms,  and  the  absence  of  a  dis- 
coverable disease  of  any  organ  are  the  salient  features  of 
adenasthenia.  It  may  be  confounded  with  carcinoma,  with 
asthenic  gastritis,  and  with  atrophy  of  the  gastric  glands. 

In  carcinoma  the  secretory  signs  may  be  similar,  but  here 
the  resemblance  ends.  The  disgust  for  certain  foods,  the 
relation  of  the  gastric  symptoms  to  the  quality  of  the  food, 
the  progressive  character  in  spite  of  the  purposive  treatment, 
the  bacteriological  signs,  possibly  the  physical  signs  of  a 
tumor,  the  motor  insufficiency,  gastric  pain,  excess  of  mucus, 
etc..  do  not  exist  in  adenasthenia.  Confusion  is  not  likely  to 
occur  unless  an  attempt  be  made  to  base  the  diagnosis  on 
the  narrow  and  misleading  hydrochloric  subacidity  alone. 

The  differentiation  of  the  functional  disorder  and  asthenic 
gastritis  is  not  difficult.  In  asthenic  gastritis  there  is  always 
an  excess  of  mucus,  and  the  secretion  can  not  be  excited 
so  readily  by  stimulants  and  b}'  electricity.  The  subjec- 
tive symptoms  of  gastritis  are  in  relation  with  the  physical 
qualities  of  the  food.  The  causation  and  the  mode  of  begin- 
ning may  suggest  the  nature  of  the  trouble.  In  gastritis  there 
may  be  symptoms,  such  as  nausea  and  vomiting,  which  are 
not  found  in  adenasthenia.  In  asthenic  gastritis  the  ferments 
are  persistently  diminished,  which  may  be  the  case  in  aden- 
asthenia.    The  dynamic  affection  is  very  rare. 

Treatment. — The  treatment  is  excitant,  the  aim  being  to 
restore  the  secretory  power  and  to  tone  the  nervous  system. 


THE  DYNAMIC  AFFECTIONS  OF  SECRETION.  303 

The  first  object  is  to  reduce  the  life  of  the  patient  to  a  physi- 
ological basis  and  to  restore  tone  and  vigor  to  the  whole 
system  by  the  use  of  tonics  and  of  hygienic  remedies  suited 
to  each  individual  case. 

As  a  chemical  remedy,  hydrochloric  acid  with  pepsin  may 
be  given  in  two  or  three  doses  during  the  period  of  diges- 
tion, but  with  no  hope  of  producing  directly  more  than  a 
purely  chemical  action.  The  effect  of  the  acid  on  intestinal 
digestion  should  be  watched.  Peptones  may,  however,  be 
administered  before  meals  to  excite  secretion,  acting  in  this 
respect  as  physiological  remedies. 

The  local  treatment  is  physiological  and  excitant — the 
Scottish  douche,  electricity,  the  intragastric  chlorid  of  sodium 
douche,  in  the  manner  recommended  in  the  chapter  on 
General  Medication. 

The  diet  should  not  vary  much  from  that  of  health — meats 
in  moderate  quantity  and  finely-divided  cereals  (since  the 
digestion  must  be  done  by  the  intestines),  vegetables,  sweets, 
and  fats.  The  starchy  foods  are  well  digested  and  they 
should  be  particularly  recommended.  Sweets  not  only  are 
useful  as  food,  but  as  a  physiological  means  of  exciting  secre- 
tion. Beer,  wines,  ale,  cider,  tea,  and  coffee  may  be  recom- 
mended in  moderation.  Fine  physical  division  of  all  of  the 
food  is  demanded  by  the  intestines,  on  which  the  brunt  of 
digestion  falls.  The  food  to  be  taken  during  the  twenty-four 
hours  should  be  divided  into  three  or  four  equal  portions. 

Calumba,  gentian,  cinchona,  and  nux  vomica  may  be  com- 
bined with  aromatic  tinctures,  and  administered  half  an  hour 
before  meals.  The  effect  of  the  excitant  treatment  should  be 
carefully  watched  and  not  pushed  too  vigorously,  and  should 
be  stopped  as  soon  as  the  secretory  activity  is  restored.  Three 
grains  of  orexinum  basicum  may  be  given  in  a  gelatin  cap- 
sule daily,  in  the  morning  at  10  o'clock,  with  a  cup  of 
bouillon,  but  the  remedy  should  not  be  continued  longer  than 
five  days  without  an  intermission.  A  powder  composed  of 
common  salt  and  chlorid  of  calcium,  taken  in  a  wineglassful 
of  a  mildly  alkaline  water  half  an  hour  before  meals,  is  an 
excellent  stimulant  of  secretion. 


304  DISEASES  OF  THE  STOMACH. 


CHAPTER  III. 
THE  MOTOR  DYNAMIC  AFFECTIONS. 

I.  SPASM  OF    THE   CARDIA. 

On  the  introduction  of  the  stomach-tube  a  sh'ght  resistance 
is  felt  by  the  experienced  finger  just  before  the  entrance  of  tlie 
tube  into  the  stomach.  Tiiis  spasmodic  contraction  of  the 
cardia  is  physiological,  and  is  often  manifest  to  a  person  when 
a  large  or  somewhat  irritating  bolus  is  swallowed.  It  is  on 
account  of  this  spasm  that  swallowed  corrosive  poisons  are 
arrested,  and  are  so  energetic  in  their  action  on  the  lower 
portion  of  the  esophagus.  Even  a  full  swallow  of  water 
occupies  about  twelve  seconds  in  passing  through  this  normal 
point  of  constriction,  as  indicated  by  the  interval  separating 
the  two  deglutition  sounds. 

Pathologically,  the  normal  constriction  or  contraction  of 
the  cardia  may  be  increased  both  when  the  cardia  is  and  is  not 
the  site  of  organic  disease.  In  esophagitis,  ulcer  of  the  cardia, 
and  sometimes  in  carcinoma,  the  stenosis  of  the  cardia  is  partly 
spasmodic.  Spasm  of  the  cardia  occurs  also  as  a  dynamic 
affection  without  a  local  anatomical  lesion.  The  stricture  of 
the  cardia  is  in  such  cases  characterized  by  the  ordinary  signs 
of  simple  spasm,  in  association  with  the  stagnation  or  reten- 
tion of  the  swallowed  food  and  the  secretions  above  it,  and 
with  the  accumulation  of  gases  in  the  stomach  below  it. 

Etiology. — Cardiospasm  (sometimes  called  esophagismus) 
is  not  a  (requent  disease.  It  may  occur  at  any  age,  and  is 
most  common  in  the  neurotic  and  the  arthritic.  Cerebral  ex- 
citement is  sometimes  the  occasion  of  its  generation,  but  the 
origin  of  the  reflex  spasm  may  be  in  any  of  the  organs 
closely  connected  with  the  nerves  of  the  cardia.  Frequently 
the  abuse  of  tobacco  is  the  most  active  factor  in  its  causa- 
tion. It  is  sometimes  produced  by  hyperesthesia  of  the 
cardia,  which  may  be  engendered  by  very  hot  or  very  cold 
drinks,  and  by  the  abuse  of  condiments.  Spasm  of  the  cardia 
sometimes  results,  by  reflex  action,  from  the  habitual  swal- 
lowing of  air,  and  we  have  seen  two  cases  developing  as  a 
result  of  arteriosclerosis,  there  being  at  the  same  time  erosions 
of  the  gastric  mucosa. 


THE  MOTOR   DYNAMIC  AFFECTIONS.  305 

Clinical  Description  and  Objective  Signs. — Spasm  of  the 
cardia  may  be  acute,  paroxysmal,  or  recurrent,  or  it  may  be 
chronic.  The  acute  attacks  last  only  a  few  days,  and  are 
characterized  by  dysphagia,  by  absence  or  delay  of  the  swal- 
lowing sounds,  and  by  strong,  but  eventually  yielding,  resist- 
ance to  the  introduction  of  the  large  and  moderately  stiff 
stomach-tubes.  The  food  accumulates  in  the  esophagus,  and 
after  a  'i^\N  mouthsful  an  effort  to  force  it  into  the  stomach 
becomes  necessary  to  relieve  the  pressure  behind  the  sternum. 
The  cardia,  however,  does  not  always  yield,  and  the  food  may 
be  regurgitated  into  the  mouth,  and  attacks  of  dyspnea, 
resembling  so-called  asthma  dyspepticum,  may  occur.  In 
the  chronic  form,  which  is  fortunately  rare,  the  dysphagia 
and  other  symptoms  occur  after  each  meal,  but  its  long 
course,  running  often  for  months  and  years,  may  be  inter- 
rupted by  periods  of  marked  improvement. 

Clinically,  three  degrees  of  the  chronic  affection  may  be 
distinguished,  two  being  characterized  by  esophageal  stagna- 
tion and  the  other  by  esophageal  retention  of  the  swallowed 
food.  The  form  with  food  retention  occurs,  with  few  excep- 
tions, only  where  the  lower  end  of  the  esophagus  is  dilated; 
the  tube  introduced  in  the  morning  before  breakfast  with- 
draws remnants  of  food  eaten  the  previous  day. 

In  the  stagnation  form  the  esophagus  is  either  found 
empty  in  the  early  morning  or  it  contains  a  noteworthy  quan- 
tity of  mucus  and  saliva.  The  stagnation  form  may  be  mild 
or  severe.  In  the  mild  form  the  spasm  occurs  chiefly  during 
the  meal ;  in  the  severe  form  the  spasm  is  more  persistent 
and  obstinate.  In  the  mild  form  the  entrance  of  food  into 
the  stomach  is  delayed  and  difficult,  but  is  effected  before  the 
next  meal ;  in  the  severe  form  the  food  is  forced  into  the 
stomach  only  after  special  efforts  and  devices,  and  the  swal- 
lowed secretions  and  the  secretion  of  the  esophagus  accumu- 
late between  meals,  and  particularly  at  night.  In  the  mild 
form  the  patient  feels  the  food  stop  before  entering  the 
stomach,  but  after  a  few  more  mouthsful  or  a  few  moments' 
delay  the  spasm  yields  and  the  food  enters  the  stomach,  to 
the  relief  of  the  patient.  In  the  severe  form  the  mere  delay 
is  not  sufficient,  but  the  accumulated  food  must  be  forced 
through  the  cardia,  often  after  drinking  a  glass  of  water.  A 
deep  inspiration  is  taken,  and  an  expiratory  effort  is  made  or 
the  thorax  is  compressed  by  the  hands,  while  the  glottis  is 
kept  closed,  sometimes  during  repeated  acts  of  deglutition. 

In  the  mild  form  the  trouble  ends  with  the  swallowing  of  the 
20 


306  DISEASES  OF  THE  STOMACH. 

meal.  In  the  severe  form  the  accumulation  of  the  secretions 
may  manifest  itself  by  non-alimentary  esophageal  vomiting. 

In  the  retention  form  the  spasm  can  not  be  completely 
overcome,  either  involuntarily  or  by  voluntary  effort,  and 
more  or  less  of  the  swallowed  food  remains  in  the  esophagus, 
which  is  usually  dilated.  The  dilatation  is  nearly  always 
symmetrical,  though  it  may  be  unilateral,  irregular,  or  saccu- 
lated. Retention  produces  much  more  serious  symptoms 
than  simple  stagnation,  such  as  dyspnea,  palpitation,  fermen- 
tation, putrefaction,  and  esophageal  alimentary  vomiting. 
The  dyspnea  occurs  not  only  during  the  meals  but  also  after 
moderate  exercise  or  effort,  or  it  may  be  paroxysmal  and 
nocturnal.  The  palpitation  occurs  intermittently  in  relation 
with  the  filling  of  the  dilated  pouch,  and  is  rapidly  relieved  by 
its  evacuation.  The  fermentation  is  usually  butyric  or  lactic, 
and  putrefaction  is  rare.  The  vomiting  often  occurs  without 
effort  or  warning,  and  may  take  place  during  sleep.  The  un- 
fortunate patient  sometimes  awakens  with  dyspnea,  cyanosis, 
and  palpitation,  and  with  the  UKuith  already  full  of  the  regur- 
gitated material. 

In  all  forms  of  the  affection  the  cardia  may  show  favoritism 
in  permitting  the  passage  of  the  various  sorts  of  food  :  now 
hot,  now  cold,  now  solid,  now  fluid  food  being  arrested. 
The  patient  must  stop  eating  once,  twice,  or  several  times 
during  the  meal  to  allow  the  cardia  to  relax,  or  he  must 
force  the  food  which  has  accumulated  in  the  esophagus 
through  the  resistant  cardia  into  the  stomach.  In  the  mild 
stagnation  form  it  is  only  necessary,  as  a  rule,  to  wait  for  a 
few  minutes,  but  in  the  severe  stagnation  and  in  the  retention 
varieties  of  the  affection  active  and  voluntary  efforts  must  be 
employed,  and  the  frequency  of  these  forcing  efforts  is  pro- 
portionate to  their  inefficiency  and  to  the  smallness  of  the 
capacity  of  the  esophagus.  If  the  esophagus  is  largely 
dilated  but  empty  when  the  meal  is  begun,  the  patient  may 
be  able  to  eat  an  ordinary  meal  before  forcing  the  food  into 
the  stomach.  The  patient,  after  the  meal,  commonly  retires 
to  a  private  corner,  takes  a  glass  of  water,  inspires  deeply, 
closes  the  glottis,  contracts  the  thorax  by  means  of  the 
e.xpiratory  muscles,  or  by  compressing  with  the  hands,  and 
repeats  the  procedure  until  the  contents  of  the  esophagus  are 
completely  or  in  part  forced  onward  into  the  stomach  or 
backward  into  the  mouth.  Patients  often  feel  water  pass  the 
lump  of  retained  food  and  hear  it  gurgle  into  the  stomach. 
The  spasm  may  be  excited  in  some  cases  only  by  the  act  of 


THE   MOTOR   DYNAMIC  AFFECTIONS.  307 

swallowing,  the  sound  or  tube  passing  into  the  stomach  with- 
out resistance. 

In  addition  to  the  esophageal  stagnation  and  retention,  the 
spasm  of  the  cardia  may  often  cause  very  distressing  tympan- 
itic distention  of  the  stomach.  The  distention  may  be  pro- 
duced by  swallowed  air  or  by  the  gases  of  chemical  decom- 
position or  of  fermentation  in  the  stomach,  the  cardia  again 
closing  after  being  forced  by  the  swallowed  food,  or  con- 
tracting as  a  result  of  the  irritation  of  the  mucous  membrane 
of  the  stomach.  This  reflex  spasm  of  the  cardia  may  exist 
without  dysphagia.  The  distention  of  the  stomach  produces 
discomfort,  dyspnea,  palpitation,  and  sometimes  painful  gas- 
trospasm,  the  attacks  lasting  from  a  {q.\\  minutes  to  several 
hours,  the  pylorus  being  also  simultaneously  closed. 

Although  the  clinical  expression  of  spasm  of  the  cardia  is 
quite  well  defined,  the  exploration  with  the  sound  furnishes 
the  most  exact  information.  The  very  soft,  flexible  tube 
passes  in  easily  for  about  14  inches,  removing  the  con- 
tents of  the  esophagus,  but  it  is  rarely  possible  to  force  it 
through  the  spasmodic  stricture.  With  the  tube  in  this  posi- 
tion, a  glass  of  water  can  be  introduced  into  the  esophagus 
and  withdrawn  by  siphonage  before  it  enters  the  stomach, 
particularly  where  the  esophagus  is  dilated.  The  stiff  English 
or  German  stomach-tubes  can  usually  be  introduced  into  the 
stomach  after  gentle  pressure  is  patiently  employed  for  one 
or  two  minutes,  but  the  flexible  English  esophageal  sounds 
of  large  caliber  pass  easily  into  the  stomach.  Sometimes  a 
sound  or  stiff  tube  may  be  introduced  without  a  perceptible 
resistance  at  the  cardia,  the  spasm  being  excited  only  by  acts 
of  swallowing.  In  the  majority  of  the  cases  of  esophagismus 
gagging  is  produced  by  the  use  of  the  tube,  and  the  patient 
often  gives  a  history  of  spasm  in  other  parts  than  the  cardia. 
The  effect  of  bromids,  combined  with  atropin  hypodermi- 
cally,  is  so  marked  in  the  relief  of  spasm  of  the  cardia  that 
the  ease  with  which  the  tube  can  be  introduced  while  the 
patient  is  under  their  influence  is  of  value  in  the  differential 
diagnosis.  If  the  tube  introduced  before  the  evening  meal 
removes  no  food  from  the  esophagus,  there  is  the  mild  stag- 
nation form.  If  food  be  removed  at  this  time,  and  if  the 
esophagus  is  empty  in  the  morning  before  breakfast  or  con- 
tains only  mucus  and  saliva,  the  severe  stagnation  form  exists. 
If  the  esophagus  contains  food  in  the  early  morning  before 
breakfast  there  is  esophageal  retention,  and  if  a  noteworthy 
quantity  of  contents  is  removed  the  esophagus  is  also  dilated. 
The  dilated  esophagus  may  hold  a  pint  or  more.     When  the 


308  DISEASES  OF  77/ E   STOMACH. 

esophagus  is  not  empty  in  tlie  early  morning  it  is  our  custom 
to  wash  out  the  esophagus  and  then  to  introduce  a  glass  of 
milk,  after  first  pushing  the  tube  well  into  the  stomach.  The 
tube  is  next  withdrawn  and  the  patient  is  given  a  glass  of 
water  and  directed  to  try  to  force  the  water  into  the  stomach. 
Ten  or  fifteen  minutes  later  the  tube  is  introduced,  and  the 
degree  of  obstruction  of  the  cardia,  and  of  dilatation  of  the 
esophagus,  is  proportionate  to  the  quantity  of  water  which 
is  recovered.  The  tube  may  then  be  pushed  on  into  the 
stomach,  and  the  obvious  inferences  may  be  made  from  the 
withdrawal  of  milk.  Before  the  entrance  of  the  tube  into  the 
stomach  it  is  not  possible  to  inflate  the  stomach  by  pumping 
in  air. 

The  deglutition  sounds  are  either  modified  or  absent.  The 
first  sound  is  usually  delayed,  and  the  second  sound,  if  heard 
at  all,  is  deferred  several  minutes  or  longer.  Swallowing  is 
followed  by  complete  silence  if  nothing  enters  the  stomach, 
and  the  deglutition  sounds  ma)'  be  heard  only  after  the  patient 
voluntarily  presses  the  arrested  food  or  fluid  through  the 
cardia.  _ 

Differential  Diagnosis. — Obstruction  of  the  cardia  may  be 
organic  or  spasmodic.  The  non-spasmodic  obstruction  may 
be  due  to  compression  by  tumors  of  the  mediastinum,  to 
Pott's  disease,  or  to  neoplasms  arising  from  the  vertebral  col- 
umn, or  to  aortic  aneurysm.  The  symptoms  incident  to  these 
diseases  should  be  sought  for  in  the  obscure  cases.  Organic 
strictures  may  be  produced  by  cancer,  ulcer,  sacculation, 
the  cicatrization  after  burns  or  after  the  swallowing  of  corro- 
sive poisons,  and  varicose  esophageal  veins. 

There  are  signs  which  distinguish  organic  from  spasmodic 
stenosis.  Organic  stricture  is  persistent :  spasmodic  stenosis 
may  be  intermittent.  Atropin  and  the  bromids  are  without 
noteworthy  influence  on  organic  stricture,  but  often  relax  the 
spasm.  Stiff  sounds  pass  a  spasmodic  stricture  more  readily 
than  the  soft  tubes,  while  the  re\'erse  is  true  of  organic  stric- 
ture. But  spasm  may  coexist  with  organic  diseases  of  the 
cardia,  and  by  the  disappearance  of  inflammatory  swelling  the 
spasm  may  be  diminished ;  improvement  is,  consequently, 
no  distinctive  criterion.  The  differentiation  should  be  based 
on  the  group  of  symptoms  or  signs. 

Carcinoma  is  most  frequent  between  thirty  and  fifty,  and  is 
regularly  progressive.  Hemorrhage  is  not  rare,  and  the  blood 
is  unlike  that  which  has  been  blackened  or  browned  by  the 
acid  of  the  gastric  juice.  Blood,  however,  may  be  vomited  after 
its  entrance  into  the  stomach.  The  cardia  is  involved  in  eight 


THE   MOTOR  DYNAMIC  AFFECTIONS.  309 

per  cent,  of  all  cancers  of  the  stomach,  but  the  neoplasm 
almost  invariably  extends  to  or  originates  in  the  stomach  or 
esophagus  ;  consequently,  the  functional  and  bacteriological 
signs  of  cancer  of  the  stomach  are  usually  present,  and  are 
valuable  aids  in  making  a  decision.  The  esophageal  contents 
are  usually  offensive,  and  blood  and  particles  of  the  neoplasm 
may  be  removed  with  the  tube.  Soft  tubes  enter  the  stomach 
more  readily  than  stiff  sounds,  and  the  caliber  of  the  stricture 
may  be  rapidly  enlarged  by  ulceration,  or  diminished  by 
swelling  and  by  the  growth  of  the  tumor.  Cancer  is  the 
most  frequent  disease  of  the  cardia,  and  the  emaciation  and 
loss  of  strength  are  greater  than  should  be  produced  by  the 
patient's  diet. 

Ulcer  involving  the  cardia  is  most  common  in  men  who 
have  passed  the  fortieth  year.  It  is  manifested  by  nausea, 
vomiting,  and  a  raw,  tearing  pain  excited  immediately  by 
swallowing,  and  located  behind  the  sternum  near  the  left  sixth 
intercostal  space  ;  from  this  point  the  pain  may  radiate  into 
the  epigastrium,  back,  and  shoulders.  Hemorrhage  is  fre- 
quent, and  the  introduction  of  the  sound  is  very  painful,  always 
injurious,  and  often  impossible.  Cicatricial  stenosis,  persistent 
or  progressive,  is  more  readily  passed  by  small  sounds,  and  is 
preceded  by  the  signs  and  symptoms  of  destructive  inflam- 
mation. The  gastric  juice  in  ulcer  of  the  cardia  is  usually 
excessively  acid,  and  many  of  the  signs  and  symptoms  of 
gastric  ulcer  accompany  it. 

Sacculation  of  the  lower  end  of  the  esophagus  is  exceed- 
ingly rare,  this  trouble  being  located  usually  at  its  upper  ex- 
tremity or  in  its  central  third.  The  esophageal  contents 
often  contain  pus  and  sometimes  blood,  and  often  ferment,  or 
sometimes  putrefy.  The  fermentation  is  usually  butyric  or 
lactic.  Both  the  tube  and  the  sound  pass  readily  when  the 
sac  is  empty,  but,  as  a  rule,  only  then.  No  abnormality  of  the 
functions  of  the  stomach  is  produced  by  sacculation. 

Varicose  esophageal  veins  are  accompanied  by  cirrhosis  of 
the  liver,  or  by  other  causes  and  signs  of  obstruction  of  the 
portal  circulation. 

Spasm  of  the  cardia,  rarer  than  either  cancer  or  ulcer,  oc- 
curs at  all  ages,  but  most  frequently  in  neurotic  and  arthritic 
patients.  The  course  is  long,  intermittent,  or  remittent.  The 
spasm  is  palpably  relieved  by  antispasmodics;  stiff  sounds 
pass  easier  than  the  soft  tubes,  and  no  change  in  the  func- 
tions of  the  stomach  takes  place.  Consequently,  normal 
functional    and   bacteriological    signs    are    against  ulcer  and 


3IO  DISEASES  OF  THE  STOMACH. 

cancer.  Tliere  is  no  spontaneous  bleeding,  nor  blood  in  the 
opening  of  tiie  tube.  The  other  signs  and  symptoms  of 
spasm  of  the  cardia  have  been  enumerated  in  its  clinical 
description. 

Treatment — The  valuable  remedies  in  the  treatment  of 
spasm  of  the  cardia  are  few.  The  etiological  and  constitu- 
tional treatment  should  not  be  neglected,  and  electricity  may 
be  tried.  Cervico-esophageal  sedative  polar  galvanization  is 
the  preferred  form,  but  it  is  no  more  and  no  less  valuable  than 
intragastric  anodal  galvanization. 

The  use  of  the  esophageal  sound  is  in  itself  sometimes 
curative,  and  is  the  mainstay  of  any  plan  of  treatment.  A 
large  fle.xible  sound  should  be  passed  through  the  cardia  and 
left  in  place  for  several  minutes.  The  sound  should  be  used 
once  a  day  in  the  stagnation  form,  preferably  before  break- 
fast. If  esophageal  retention  is  present,  the  sound  should  be 
introduced  before  each  meal.  The  lower  end  of  the  tube 
may  be  smeared  with  an  ointment  of  cocain  (Rosenheim),  or 
a  small  piece  of  sponge  attached  to  a  silk  thread  running 
through  the  tube  may  be  placed  within  the  eye  of  the  tube, 
saturated  with  a  solution  of  cocain,  which  is  squeezed  out 
after  the  tube  is  against  the  cardia  by  introducing  a  tube- 
guard  (Penzoldt).  If  the  esophagus  is  dilated,  its  contents 
should  be  washed  out  at  bedtime.  It  is  a  most  excellent  plan 
to  introduce  all  the  food  through  the  stomach-tube. 

Bromid  of  potassium  is  often  palliative,  but  sometimes  does 
little  good  unless  given  in  large  doses.  The  spasm  often 
returns  after  the  bromism  subsides,  but  the  remedy  is  in- 
dicated as  a  palliative,  unless  there  is  excessive  hydrochloric 
acidity  of  the  gastric  contents.  Nitrate  of  silver  is  then 
much  better,  and  in  the  simple  cases  also  it  often  proves  of 
more  service  than  do  the  bromids.  The  extracts  of  coca 
and  of  hyoscyamus  washed  down  with  chloroform  water  are 
very  beneficial.  These  remedies  should  be  given  half  an 
hour  before  meals.  It  is  very  important  to  control  excessive 
hydrochloric  secretion  and  to  prevent  butj'ric  acid  fermenta- 
tion both  in  the  esophagus  and  stomach. 

The  diet  is  often  too  restricted.  The  one  essential  is 
that  it  should  not  be  irritating,  and  condiments  and  acids 
and  half-mastication  of  the  food  should  not  be  permitted. 
All  the  food  and  water  should  be  taken  in  three  meals,  noth- 
ing being  permitted  during  the  intervals.  The  diet  should 
also  satisfy  any  peculiarity  of  the  spasm,  which  sometimes 
shows  a  repugnance  for  certain  foods.     In  other  respects,  the 


THE   MOTOR  DYNAMIC  AFFECTIONS.  3II 

diet  is  selected  in  reference  to  the  condition  of  the  stomach 
and  the  intestines,  the  needs  of  nutrition,  and  also  to  the  con- 
dition of  other  organs  when  diseased,  and  coarse  or  solid  food 
may  sometimes  be  employed  as  a  means  of  dilating  the  cardia. 


II.  SPASM  OF  THE  PYLORUS. 

The  pylorus  is  physiologically  the  most  important  sphinc- 
ter of  the  digestive  tube,  exceeding  in  the  variety  and  value 
of  its  work  not  only  the  cardia  and  the  anus,  but  also  the 
ileocecal  valve  and  the  duodenojejunal  constriction.  It  con- 
trols gastric  digestion  by  regulating  the  time  during  which 
the  food  is  subjected  to  the  churning  movements,  to  the 
transforming  gastric  juice,  to  the  absorbent  surface  of  the 
stomach,  and  to  the  action  of  the  saliva.  It  regulates  the 
supply  of  nutritive  material  to  the  intestines  without  the  in- 
terference of  the  will.  It  separates  the  two  chief  divisions 
of  the  digestive  tube,  protecting  both  the  stomach  and  the 
intestines.  Normally,  there  is  no  reflux  through  it  to  disturb 
the  stomach,  and  no  harm  should  come  through  it  to  the 
intestines.  It  controls  the  gateway  to  nutrition.  But  its 
work  is  not  done  without  favoritism,  for  it  often  protects  the 
intestines  at  the  cost  of  slow  starvation  and  of  injury  to  the 
stomach.  While  acting  normally  it  may  not  do  harm,  and 
the  disturbance  produced  by  it  when  diseased  corresponds  to 
the  importance  of  its  work  in  health.  One  of  its  chief  func- 
tional disorders  is  spasm. 

Spasm  of  the  pylorus  is  either  primary  or  secondary.  The 
secondary  spasm  of  the  pylorus  is  common  in  ulcer,  in  cancer, 
in  hypersthenic  gastritis,  in  adenohypersthenia  gastrica,  and  in 
excessive  secretory  activity  accompanying  stagnation  and  re- 
tention. It  consequently  plays  an  important  part  in  the  evolu- 
tion and  in  the  genesis  of  the  symptoms  of  acute  and  chronic 
hypersthenic  gastritis,  and  of  complicated  forms  of  myasthenia. 
The  disease  produces  the  spasm,  and  the  spasm  causes  or 
increases  stagnation  or  retention,  with  consequent  irritation  of 
the  mucous  membrane  of  the  stomach,  excessive  peristalsis 
or  gastrospasm,  and  often  vomiting.  A  vicious  gastric  circle 
thus  becomes  established. 

But  spasm  of  the  pylorus  occurs  frequently  as  a  primary 
dynamic  affection — a  morbid  entity  with  a  distinctive  expres- 
sion and  with  a  proper  rational  treatment.  Its  existence  can 
be  established  only  by  clinical  observation,  and  its  frequency 
by  the  recognition  of  the  vicious  circle  of  which  it  forms  a 


312  DISEASES  OF  THE  STOMACH. 

part,  and  by  observing  the  method  b}-  which  this  same  circle 
is  broken. 

Etiology. — Like  spasm  of  the  cardia,  spasm  of  the  pylorus 
is  most  common  in  neurotic  and  arthritic  patients,  and  it  may 
be  occasioned  by  shock,  anxiety,  worrj',  or  prolonged 
mental  or  moral  strain.  It  may  occur  as  an  accident,  the  mere 
manifestation  of  a  dietetic  error,  or  the  effect  of  very  cold 
drinks,  the  protection  of  the  intestines  necessitating  an  acute 
disturbance  of  digestion.  Spasm  of  the  pylorus  is  an  almost 
constant  accompaniment  of  gall-stone  colic  and  of  pyloric 
hyperesthesia,  and  it  may  produce  complete  occlusion  for 
several  days.  It  is  common  in  the  acute  diseases  of  the 
intestines,  particularly  when  nausea  and  vonfiiting  are  present. 
When  the  body  of  any  of  the  hollow  organs  that  are  closed  by 
sphincters  becomes  relatively  weak,  the  antagonistic  sphincter 
muscle  may  remain  contracted.  This  is  very  likely  the 
genesis  of  pyloric  spasm  occurring  in  old  age,  and  during 
convalescence  from  severe  diseases. 

Clinical  Description. — Pyloric  spasm,  like  spasm  of  the 
cardia,  is  digestive  and  periodical,  or  it  is  more  persistent. 
Consequently,  it  produces  either  stagnation  or  retention  and 
their  respective  consequences. 

One  of  the  most  common  symptoms  is  gastric  flatulency. 
The  swallowed  air  and  the  gases  of  chemical  decomposition 
and  of  fermentation  when  it  is  present,  accumulate  in  the 
stomach,  and  are  got  rid  of  by  belching  or  finally  by 
the  relaxation  of  the  pylorus  and  their  rapid  escape  into  the 
duodenum.  This  sudden  relief  by  the  rapid  and  perceptible 
evacuation  of  the  stomach  is  characteristic. 

In  the  severe  cases  there  are  often  painful  gastric  peristal- 
sis and  agonizing  pyloric  colic,  which  may  end  suddenly 
with  the  relaxation  of  the  pylorus,  or  may  recur  intermit- 
tently until  the  stomach  is  empty,  or  cease  after  copious 
alimentary  vomiting. 

There  is  no  discomfort  when  the  stomach  is  empty,  but 
the  pain  may  continue  as  long  as  the  food  and  digestive  or 
fermentative  products  remain  in  the  stomach.  In  retention 
the  symptoms  may  become  continuous  and  the  stomach  may 
ultimately  reject  everything  introduced  into  it. 

The  objective  signs  are  much  more  characteristic  than  the 
subjective  symptoms.  In  some  cases  the  pylorus  can  be 
felt  as  a  firm  cylinder  moving  up  and  down  with  the  dia- 
phragm. During  digestion  there  is  no  intermittent  palpable 
bubbling  through  it,  nor  does  it  become  alternately  hard  and 
soft.     The  intermittent  pyloric  spurt  is  not  heard  either  after 


THE   MOTOR  DYNAMIC  AFFECTIONS.  313 

a  glass  of  water  or  during  the  digestion  of  a  meal.  The 
pyloric  evacuation  sound  may  be  absent  when  there  is  visible 
or  distinctly  palpable  gastric  peristalsis.  These  abnormalities 
disappear,  either  spontaneously  or  intermittently,  under  the 
influence  of  antispasmodic  treatment. 

Artificial  inflation  of  the  stomach  is  easy  and  the  viscus  re- 
mains distended  much  longer  than  when  it  is  normal.  The  gas 
or  air  can  not  be  massaged  into  the  duodenum  as  in  health. 

In  the  simple  cases  gastric  absorption  is  normal.  Secre- 
tion may  be  normal  or  may  be  excessive,  but  the  abnor- 
mality usually  disappears  with  the  restoration  of  the  motor 
function.  The  characteristic  functional  sign  is  intermittent 
stagnation  or  retention.  After  the  test-breakfast  there  is  an 
excessive  quantity  of  contents  of  high  specific  gravity  (above 
1015)  and  containing  an  excessive  quantity  of  digestive  pro- 
ducts. There  may  be  mild  or  severe  stagnation  or  retention, 
but  the  motor  insufficiency  in  a  particular  case,  whatever  be 
its  degree,  may  spontaneously  and  suddenly  disappear,  or 
may  be  rapidly  improved  by  sedative  and  soothing  medica- 
tion. This  distinctive  sign  is  never  met  with  in  myasthenia. 
If  stagnation,  as  a  result  of  pyloric  spasm,  occur  in  adeno- 
hypersthenia  gastrica,  it  is  rapidly  relieved  by  a  milk  diet  with 
large  doses  of  the  alkalies,  but  the  excessive  secretion  is  more 
rebellious.  In  stagnation  or  retention  due  to  myasthenia  the 
excessive  secretion  may  be  controlled,  but  the  motor  insuffi- 
ciency disappears  very  slowly  and  gradually. 

Treatment. — The  treatment  of  primary  spasm  of  the 
pylorus  is  very  simple,  but  not  always  rapidly  successful. 
Measures  to  improve  the  tone  and  strength  and  to  allay  the 
irritability  of  the  nervous  system  are  naturally  in  place.  If 
retention  be  present,  the  stomach  should  be  daily  washed  out, 
but  in  stagnation  only  when  there  is  fermentation. 

The  diet  should  be  soothing,  mild  in  its  action  on  secre- 
tion, and  easily  evacuated,  and  should  also  be  selected  with 
a  view  to  its  resistance  to  fermentation  if  the  motor  insuffi- 
ciency be  pronounced.  Consequently  no  particular  diet  will 
suit  every  case. 

Of  the  physical  remedies,  cervicogastric  galvanization  and 
the  Winternitz  or  a  hot  compress  (coil  over  moist  flannel) 
may  be  employed  during  digestion.  Nitrate  of  silver  is  valu- 
able if  the  stomach  is  morbidly  sensitive  or  secretes  exces- 
sively, or  when  there  is  hyperesthesia  of  the  pyloric  mucous 
membrane.  The  extracts  of  coca  and  belladonna  should  be 
given  before  each  meal,  and  if  there  is  much  pain  codein 
phosphate  should  be  given  hypodermically,  or  chloral  hydrate 


314  DISEASES  OF  THE  STOMACH. 

may  be  given  bv  rectiuii.  It  is  bad  practice  to  give  these 
remedies  by  mouth  for  the  relief  of  painful  p)'loric  spasm. 
Hot  drinks  may  be  given  and  heat  may  be  applied  externally, 
or  the  stomach  may  be  washed  out  and  left  empty. 


III.  GASTROSPASM. 

Tonic  spasm  of  the  stomach  may  be  a  symptom  or,  rarely, 
a  distinct  morbid  entity  occurring  without  any  organic 
change  in  the  mucous  membrane. 

Etiology. — Symptomatic  gastrospasm  occurs  in  pyloric 
obstruction,  at  times  during  the  digestive  period,  and  at 
times  during  the  period  of  normal  repose,  on  account  of  the 
effort  of  the  stomach  to  evacuate  the  retained  chyme.  But 
the  stomach  when  empty  again  relaxes.  In  hypersthenic 
gastritis  and  in  adenohypersthenia  gastrica  the  stomach 
may  be  resistant  and  rigid,  and  also  small  when  it  is  not 
full.  The  spasm  of  the  stomach  in  these  diseases  and  in 
ulcer,  like  pyloric  spasm,  is  due  to  the  irritation  or  hyper- 
esthesia of  the  mucous  membrane.  The  chronic  asthenic 
gastritis  which  occurs  in  advanced  arteriosclerosis  may  be 
accompanied  by  paro.xysms  of  painful  gastrospasm.  and  these 
attacks  may  occur  either  when  the  stomach  is  empty  or 
during  digestion.  Tabes  may  rarely  be  manifested  by  crises 
of  gastro-intestinal  tonic  spasm.  A  small,  contracted,  hyper- 
trophied  stomach  in  a  permanent  form  is  a  sequel  of  long 
rumination.  In  cases  of  chronic  and  periodical  vomiting, 
with  complete  gastric  intolerance,  the  stomach  is  contract- 
ured,  and  the  same  condition  is  a  result  of  acute  nicotin- 
poisoning  and  probably  occurs  in  meningitis. 

Clinical  Description. — Primary  gastrospasm  may  or  may 
not  be  painful,  or  may  be  only  periodically  painful,  and  par- 
ticularly so  after  the  ingestion  of  food.  The  sensation  of 
constriction  of  the  stomach,  often  felt  and  complained  of  by 
the  patient,  is  not  always  relieved  by  empt\'ing  the  stomach. 
The  capacity  of  the  stomach,  and  consequently  its  surface 
area  also,  is  small.  If  there  be  vomiting  or  discomfort,  or 
even  severe  pain,  a  quantity  of  food  that  is  large  as  regards 
the  size  of  the  stomach  always  produces  these  symptoms, 
but  small  meals  may  be  well  borne.  Inflation  of  the  stomach 
excites  nervousness,  local  distress,  and  pain.  When  the 
stomach  is  empty  the  epigastrium  is  depressed,  and  may 
become  prominent  after  meals.  Above  the  depression,  and 
well   up  under   the  left  costal  border,  the   rigid  contractu  red 


THE   MOTOR  DYNAMIC  AFFECTIONS.  315 

Stomach  can  sometimes  be  felt  moving  up  and  down  with 
the  diaphragm.  The  epigastric  prominence  is  produced  by 
the  hard,  smooth  stomach,  manifesting  no  palpable  peristaltic 
movements.  In  neither  case  is  the  stomach  tender.  There 
is  no  chemical  abnormality  of  the  test-breakfast  contents  if 
the  bread  has  been  thoroughly  masticated.  The  stomach 
may  be  too  rapidly  evacuated,  but  more  frequently  the  py- 
lorus is  also  tightly  closed. 

Diagnosis. — The  diagnosis  of  the  dynamic  affection — the 
course  of  which  may  be  long  or  short,  remittent  or  intermit- 
tent, beginning  and  ending  suddenly  without  apparent  cause — 
must  be  made  by  exclusion  and  by  the  presence  of  its  physical 
signs.  The  gastrospasm  can  only  be  rightfully  considered 
primary  in  the  absence  of  the  diseases  of  which  it  may  be  a 
symptom.  Fortunately,  the  signs  of  these  diseases  are  dis- 
tinctive. 

Treatment. — The  treatment  is  almost  exclusively  dietetic. 
The  bromids  only  act  as  palliatives,  cannabis  indica  is  uncer- 
tain, and  belladonna  is  of  no  benefit.  Aconitia  and  codein 
are  of  the  greatest  value,  and  in  combination  have  a  marked 
influence  on  the  trouble.  Sedative  galvanization  and  a  hot 
compress  may  be  tried.     Vigorous  massage  is  also  beneficial. 

The  diet  in  the  beginning  should  be  soothing  and  small  in 
quantity,  and  when  well  borne  nothing  is  better  than  hot 
milk.  The  quantity  of  the  milk  should  be  gradually  increased, 
and  after  a  week  cereals,  and,  later,  meats,  should  be  added  to 
the  diet,  the  object  being  gradually  to  render  the  stomach 
tolerant  of  larger  and  larger  quantities  of  food  which  excites 
it  little  and  leaves  it  rapidly. 


IV.  TORMINA  VENTRICULI  NERVOSA. 

Excessive  and  visible  peristalsis  of  the  stomach  as  a  simple 
dynamic  affection  is  very  rare.  The  phenomenon  is  nearly 
always  a  symptom  either  of  pyloric  or  duodenal  obstruction 
or  of  gastroptosis. 

Peristalsis  may  infrequently  be  palpable  or  visible  during 
normal  digestion.  Pathologically,  gastric  peristalsis  may  also 
occur  periodically,  or  persistently  during  the  period  of  nor- 
mal repose.  It  is  then  either  a  symptom,  the  stomach  con- 
taining either  food  or  gas,  or  possibly  it  is  a  distinct  morbid 
entity. 

The  dynamic  form  occurs  in  neurotics  and  neuropaths — 
particularly  in   hysteria  and   in   neurasthenia.     It  may  then 


l6  DISEASES  OF  THE  STOMACH. 


exist  alone,  or  ina)'  be  associated  with  excessive  intestinal 
peristalsis. 

The  visible  and  palpable  peristalsis  nia}-  occur  when  the 
stomach  contains  no  food,  but  it  is  most  active  during  diges- 
tion. It  may  also  be  excited  by  gently  stimulating  the  skin 
over  the  epigastrium  with  the  tips  of  the  fingers,  or  by  cold, 
or,  better,  by  introducing  food  or  cold  water  into  the  stomach. 
It  seems,  at  times,  to  be  a  mere  effort  to  rid  the  stomach  of  gas, 
and  often  ceases  with  its  evacuation.  Excitement  may  either 
stop  or  start  it. 

As  the  patient  lies  quietly  on  the  back,  the  peristaltic  wave 
emerges  from  beneath  the  left  costal  border,  rises  prominently 
into  view,  and  falls  beneath  the  linea  alba,  to  rise  again  slightly, 
and  finally  to  disappear  at  the  pylorus.  The  wave  may  also 
be  antiperistaltic,  and  the  circuit  may  be  traversed  several 
times  in  a  minute.  The  agitation  may  be  accompanied  by 
churning  and  gurgling  noises,  but  the  peristalsis  is  never  pain- 
ful. It  may  continue  day  and  night,  and  produce  insomnia. 
Seldom  nausea  and  vomiting  and  belching  occur.  There  are 
no  secretory  or  bacteriological  signs.  The  patient  com- 
plains of  the  perceptible  movements  in  the  abdomen  and 
of  the  peculiar  uneasiness  which  accompanies  them. 

The  diagnosis  is  readily  made  by  inspection  and  palpation, 
and  it  is  not  difficult  to  locate  the  trouble  in  the  stomach  by 
the  aid  of  the  physical  signs.  The  affection  may  exist  without 
the  peristaltic  waves  being  visible,  the  subjective  sensations 
described  by  the  patient  first  directing  attention  to  it.  The 
dynamic  affection  occurs  in  nervous  persons  in  the  complete 
absence  of  signs  of  obstruction  to  the  evacuation  of  the 
stomach  and  in  the  absence  of  gastroptosis,  and  is  relieved 
by  codein,  electricity,  and  rest.  On  careful  study,  the  simple 
dynamic  affection  will  be  found  exceedingly  rare. 

The  treatment  consists  of  rest  in  bed,  an  indifferent  diet, 
and  strong  intraventricular  or  epigastric  faradization,  or, 
preferably,  anodal  sedative  galvanization.  The  general  ner- 
vous system  should  be  given  tone  and  strength  by  hydro- 
therap}%  good  hygiene,  and  reconstituent  medication. 


V.  ERUCTATIO  NERVOSA. 

Belching  is  common  both  in  health  and  disease,  and  occurs 
or  is  voluntarily  induced  in  order  to  relieve  the  stomach  of 
accumulated  gas  which  has  been  swallowed  with  the  food  or 
drinks  or  saliva,  or  which  has  been  generated  in  the  organ 


THE   MOTOR  DYNAMIC  AFFECTIONS.  317 

chemically  or  by  germs,  or  which  has  been  regurgitated  from 
the  intestines.  This  simple  or  symptomatic  belching  ends 
with  a  few  easy  eructations  of  the  gas  contained  in  the 
stomach. 

Eructatio  nervosa  is  a  dynamic  affection  of  the  stomach 
characterized  by  periodical  and  paroxysmal  attacks  of  rapidly 
repeated  and  often  very  noisy  belching.  It  is  essentially  a 
reflex  effort,  aided  sometimes  by  volition,  to  relieve  a  domi- 
nant and  peculiar  sensation.  The  affection  is  composed  of 
two  factors — the  sensation  associated  in  consciousness  with 
the  accumulation  of  gas  in  the  stomach,  and  the  effort  to 
relieve  it  by  belching.  The  stomach  actually  may  or  may 
not  contain  an  excess  of  gas. 

It  is  claimed  by  some  that,  in  this  affection,  the  stomach 
draws  in  and  drives  out  forcibly  atmospheric  air,  after  the 
manner  of  a  Politzer  inflator,  the  suction  and  expulsion 
being  produced  by  relaxation  and  contraction  of  the  muscu- 
lar layer.  Oser  notes  its  occurrence  in  individuals  who 
manifest  in  other  ways  excessive  peristaltic  activity,  and 
maintains  that  the  cardia  is  not  relaxed,  as  very  great  in- 
crease of  abdominal  pressure  does  not  expel  the  gas.  In 
Stiller's  opinion,  paresis  of  the  cardia  is  the  essential  condi- 
tion, but  aided  by  some  expulsive  force,  it  being  impossible 
to  exclude  contractions  of  the  stomach.  He  notes,  in  support 
of  this  theory,  that  the  affection  is  often  associated  with 
paresis  or  spasm  of  the  throat,  esophagus,  or  stomach.  Both 
Oser  and  Stiller  consider  eructatio  nervosa  distinct  from 
esophageal  belching. 

Bouveret  thinks  that  the  essential  factor  is  clonic  spasm  of 
the  pharynx,  and  is  more  than  inclined  to  consider  the  affec- 
tion a  neurosis  of  the  pharynx,  or  aerophagia.  As  a  result  of 
close  observation,  he  separates  the  belching  into  two  parts — 
the  swallowing  and  the  expulsion  of  air.  The  convulsive 
swallowing  is  accompanied  by  tight  closure  of  the  lips  and 
mouth,  by  elevation  of  the  larynx,  and  by  a  single  short  but 
audible  sound.  The  expulsion  is  produced  by  the  contrac- 
tions of  the  esophagus,  and  is  accompanied  by  a  long,  loud, 
vibratory,  and  characteristic  noise.  Some  of  the  swallowed 
air  may  enter  and  accumulate  in  the  stomach  and  aid  in  the 
production  of  the  second  sound  by  its  occasional  expulsion. 

None  of  these  explanations  is  satisfactory,  and  least  of  all 
the  one  which  makes  the  affection  a  simple  aerophagia.  A 
part  of  the  seemingly  hysterical  effort  does  not  constitute  the 
disease,  which  is  the  reflex  and  sometimes  partly  voluntary  and 
repeated  employment  of  the  usual  means  of  getting  gas  out  of 


3l8  DISEASES  OE  THE  STOMACH. 

the  stoiiiacli.aiul  in  eiiictatio  nervosa, also  in  order  to  relieve  a 
peculiar  and  uncomfortable  <^astric  sensation.  It  is  the  sensa- 
tion that  bothers  the  patient  more  than  does  the  belching, 
and  that  distinguishes  the  affection  from  the  nervous  and 
usually  hysterical  swallowing  and  noisy  expulsion  of  air  from 
the  esophagus.  Aerophagia  nervosa  is  an  imitative  affection, 
a  play  to  an  audience  or  a  plea  for  sympathy — a  simple 
psychosis.  The  attacks  are  immediately  arrested  by  holding 
the  mouth  open,  thus  rendering  the  swallowing  of  the  air 
impossible. 

If  a  tube  be  introduced  into  the  esophagus,  air  is  drawn  in 
during  each  ins[)iration.  The  same  phenomenon  is  noticeable 
if,  by  muscular  action  or  relaxation,  either  end  of  the  esopha- 
gus becomes  open  during  respiration.  In  voluntary  esopha- 
geal belching  the  mechanism  is  very  simple.  During  an 
inspiratory  act  while  the  glottis  is  closed,  the  larynx  is  lifted 
upward  and  forward,  and  the  air  rushes  in,  sometimes  with 
an  audible  sound.  The  larynx  is  allowed  to  fall  back,  and 
expiratory  effort  while  the  glottis  is  closed  forces  the  air  out 
with  more  or  less  noise.  In  aerophagia  nervosa  the  procedure 
is  the  same,  but  is  involuntary,  and  the  contractions  of  the 
esophagus  chiefly,  or  unaided  by  expiration,  force  out  the  air. 
If  the  cardia  be  open,  the  opening  of  the  pharyngeal  end  of 
the  esophagus  by  lifting  the  larynx  upward  and  forward 
enables  the  gas  to  escape,  provided  (as  is  nearly  always  the 
case  when  the  stomach  is  distended  with  gas  or  contracted 
on  its  contents)  that  it  is  subjected  to  a  suf^cient  pressure  to 
overcome  the  resistance  of  the  atmosphere.  If  the  cardia  is 
not  open  it  may  yield  to  the  slight  aspiratory  suction  exerted 
during  the  expulsion  of  the  esophageal  air  by  the  full  cur- 
rent of  a  forced  expiration,  or  to  the  suction  exerted  by  an 
expiratory  act  while  the  glottis  and  the  pharyngeal  end  of  the 
esophagus  are  closed;  or  it  would  seem  that  the  cardia  is 
sometimes  opened  by  some  of  the  air  being  carried  by  esopha- 
geal peristalsis  into  the  stomach,  furnishing  an  opportunity 
for  gas  subjected  to  a  higher  pressure  to  escape.  These  are 
only  the  occasions  of  gastric  belching,  the  expulsive  force 
being  furnished  by  the  contractions  (or  elasticity  if  the 
stomach  is  distended)  of  the  stomach  or  by  intra-abdominal 
pressure.  The  peculiarity  of  eructatio  nervosa  is  that 
these  aids  to  belching  are  in  whole  or  in  part  repeatedly  and 
paroxysmally  employed  to  relieve  a  distressing  gastric  sensa- 
tion which  may  or  may  not  be  actually  associated  with  an 
excess  of  gas  in  the  stomach,  and  which  may  be  relieved  by 
the   escape  of  gas    or   may   persist   even   after  the   stomach 


THE   MOTOR  DYNAMIC  AFFECTIONS.  319 

empties  itself  or  has  been  emptied  by  a  tube.  Such  is  the 
double  nature  of  the  affection. 

Etiology. — The  affection  is  most  common  in  introspective, 
nervous,  and  impressionable  people.  It  develops  in  the  same 
soil  as  do  hysteria  and  neurasthenia,  and  hysterical  and 
neurasthenic  forms  might  justly  be  described,  the  attacks 
sometimes  degenerating  into  feeble  efforts  to  excite  sympathy 
or  to  attract  attention.  Shock,  anger,  misfortune,  great  sor- 
rows, and  depressing  emotions  are  given  by  patients  as  the 
occasions  or  causes  of  it.  Masturbation,  excessive  venery, 
and  other  abuses  are  sometimes  associated  with  it;  indeed, 
many  of  the  individuals  are  habit-forming  neurotics  or  neuro- 
paths.    It  is  somewhat  more  frequent  in  women  than  in  men. 

The  affection  is  sometimes  associated  with  other  diseases  of 
the  stomach,  particularly,  in  our  experience,  with  the  displace- 
ments of  the  organ.  In  one  case  the  attacks  seemed  to  be 
associated  with  and  dependent  upon  the  accumulations  of 
gas  in  the  dilated  splenic  flexure  of  the  colon.  It  is  some- 
times accompanied  by  gastric  and  intestinal  "  peristaltic  un- 
rest." It  would  seem  that,  apart  from  the  displacements  of 
the  stomach,  its  association  with  other  diseases  of  the  stom- 
ach is  accidental. 

Clinical  Description. — The  affection  often  develops  and 
terminates  suddenly  and  without  evident  cause.  The  appetite, 
digestion,  and  nutrition  may  all  be  normal,  but  it  is  quite 
common  for  these  patients  to  be  emaciated  and  asthenic,  and 
to  complain  of  fullness  and  constriction  of  the  stomach  after 
meals. 

The  occurrence  of  the  paroxysm  has  no  constant  relation 
with  the  taking  of  food  or  with  its  quantity  or  quality  ;  but 
anger,  fear,  intense  emotions  of  any  kind,  pressure  on  hys- 
terical zones,  may  induce  the  attacks,  and  the  peculiar  causa- 
tion defines  a  cerebrogastric  group  of  cases.  In  other  in- 
stances the  paroxysms  seem  to  be  the  quiet  and  natural  effort 
to  empty  a  displaced  and  flatulent  stomach,  or  one  whose 
pylorus  is  spasmodically  or  organically  obstructed.  The 
belching,  in  keeping  with  the  genesis  of  the  attacks,  may  or 
may  not  give  relief. 

The  paroxysms  recur  periodically,  sometimes  after  regular 
intervals,  but  more  commonly  suddenly  and  unexpectedly. 
They  may  continue  during  meals,  begin  after  meals,  or  only 
when  the  stomach  is  in  functional  repose  ;  but,  as  a  rule,  they 
cease  at  night,  and  never  continue  during  sleep.  An  attack 
may  begin  at  night.  The  eructated  gases  are  chiefly  those 
found  in  expired  and  swallowed  air. 


320  DISEASES  OF  THE  STOMACH. 

The  paroxysms  vary  in  intensity  and  duration.  There 
may  be  a  number  of  noisy  eructations  separated  by  a  few 
moments  of  quietude  ;  or  the  paroxysms  may  last  several 
minutes,  with  ten  to  twenty  eructations  or  efforts  each  minute  ; 
or  the  attacks  may  be  severe,  lasting,  with  short  remissions,  or 
intermissions,  for  several  hours,  or,  rarely,  one  or  two  days,  or 
even  months. 

The  paroxysms  are  noisy,  embarrassing,  often  banishing 
the  person  from  society  and  interfering  with  work,  uncontrol- 
lable by  the  will,  sometimes  distressing  and  accompanied  by 
excitement  and  by  an.xiety,  and  are  exceptionally  followed  by 
depression.  The  mild  attacks  have  none  of  these  serious 
features,  and  a  few  free  eructations  give  complete  relief 

Diagnosis. — The  periodical,  paroxysmal  attacks,  when 
clearly  described  by  the  patient  or  once  observed  by  the 
physician,  are  characteristic.  The  patient  is  also  most  com- 
monly a  neurotic  or  a  neuropath. 

The  complete  absence  of  signs  of  organic  disease  of  the 
stomach  is  of  very  great  negative  value.  The  peculiar  gas- 
tric sensation,  with  the  induced  efforts  to  relieve  it,  when  dis- 
sociated with  other  functional  trouble  of  the  stomach,  is 
characteristic;  but  the  discovery  of  abnormal  functional  and 
bacteriological  signs  does  not  necessarily  exclude  eructatio 
nervosa. 

It  is  useless  to  analyze  the  belched  gas,  as  this  will  always 
contain  the  constituents  of  expired  air.  Easier  and  more 
practical  is  the  search  for  bacteriological  signs — organic  acids, 
excessive  or  peculiar  germ  growth,  and  gas  formation  in  the 
fermentation  tubes.  In  simple  and  symptomatic  belching 
the  eructated  gas  may  be  swallowed  air  or  gas  formed  by  fer- 
mentation or  by  chemical  decomposition.  The  absence  of 
bacteriological  signs  and  of  gastric  flatulency  during  the 
paro.xysm  reveals  the  nervous  nature  of  the  trouble  ;  but 
their  presence  does  not  exclude  it. 

Treatment. — The  treatment  is  chiefly  constitutional  and  is 
directed  toward  building  up  the  nervous  system.  Change  of 
scene,  rest,  hydrotherapy,  electricity,  and  strong  moral  con- 
trol and  suggestion  are  valuable  remedies.  The  individual 
himself,  as  well  as  any  associated  or  causative  disease,  should 
be  appropriately  treated. 

Few  drugs  are  of  value.  In  the  non-neurasthenic  cases, 
the  bromids  sometimes  do  good.  Arsenic  is  seldom  bene- 
ficial. Opium,  belladonna,  and  similar  drugs  have  proved 
useless  in  our  hands. 

The  intragastric  spray  is  the  most  valuable  single  remedy. 


THE   MOTOR  DYNAMIC  AFFECTIONS.  32 1 

Warm  water  alone  may  be  used,  or  warm  water  followed 
immediately  after  its  removal  by  cold  water,  or  a  solution  of 
nitrate  of  silver  (five  grs.  to  the  pint  of  distilled  water).  The 
prolonged  paroxysms  may  be  cut  short  by  20  grs.  of  chloral 
hydrate  per  rectum. 


VI.  HABITUAL  REGURGITATION. 

During  the  course  of  normal  digestion  some  of  the  con- 
tents of  the  stomach  may  be  regurgitated  into  the  throat  or 
mouth.  Food  is  then  commonly  brought  up,  in  company  with 
swallowed  air  or  gas,  and  relieves  a  sensation  of  fullness  in  the 
stomach  ;  but  the  regurgitated  matter  may  also  be  entirely 
fluid.  This  form  of  regurgitation  is  often  voluntary,  or  it 
may  be  a  mere  accident  or  episode  of  normal  digestion.  Patho- 
logically, regurgitation  may  be  a  symptom  of  a  disease  of  the 
stomach,  particularly  when  such  disease  is  accompanied  by 
stagnation  or  retention ;  but  regurgitation  exists  also  as  an 
idiopathic  dynamic  affection  of  the  stomach,  as  a  distinct 
morbid  entity. 

Clinical  Description. — Habitual  regurgitation  is  easy,  in- 
voluntary, effortless,  without  nausea  or  increased  salivary 
secretion,  not  preceded  by  conscious  contraction  of  the  stom- 
ach, and  always  occurs  during  the  normal  period  of  gastric 
digestion.  The  matter  regurgitated  is  never  solid,  but  always 
fluid  or  liquid,  and  of  such  a  composition  and  taste  as  would 
be  expected  of  the  contents  of  the  normal  stomach  at  the 
moment  when  it  occurs.  The  liquid  rises  into  the  throat  or 
mouth,  and  not  simply  into  the  esophagus,  and  is  either  ex- 
pectorated or  is  swallowed  again  through  natural  feelings  of 
delicacy.  It  is  never  remasticated  with  enjoyment  and  again 
swallowed,  as  in  rumination. 

The  regurgitations  recur  quite  regularly  after  each  meal, 
are  several  times  repeated,  and  are  noteworthy  in  quantity. 
Rarely,  the  quantity  of  food  lost  by  spitting  it  out  is  so  great 
as  to  produce  inanition  and  to  confine  the  weak  patient  in 
bed.  This  severe  form  is  likely  to  be  confounded  with  habitual 
vomiting. 

The  regurgitation  may  often  be  suppressed  by  a  strong 
effort  of  the  will  or  by  swallowing  at  the  moment  when  it 
begins.  Occurring,  when  not  resisted,  without  discomfort, 
when  voluntarily  prevented  it  is  usually  accompanied  by  a 
sensation  of  fullness  or  distention  in  the  lower  part  of  the 
esophagus. 


322  DISEASES  OF   THE   STOMACH. 

Diagnosis. — Regurgitation  will  not  be  confounded  with 
habitual  vomiting  when  the  distinctive  characters  already 
given  are  noticed  ;  but  it  may  be  mistaken  for  esophageal 
regurgitation,  particularly  in  esophageal  pocketing  and  the 
stagnation  or  retention  of  esophageal  stenosis.  The  matter 
regurgitated  from  the  esophagus  has  never  entered  the 
stomach,  and  consequent!)^  contains  neither  free  nor  organic- 
ally combined  IlCl.nor  gastric  ferments,  nor  products  of  gas- 
tric digestion.  The  esophageal  regurgitated  matter  often  con- 
tains pus,  and  consists  largely  of  mucus,  sometimes  foul  or 
fermenting;  the  gastric  contents,  having  markedly  contrast- 
ing and  characteristic  properties,  can  be  obtained  through  a 
tube  introduced  into  the  stomach.  The  differentiation  is 
easy  after  suspicion  is  once  aroused  and  the  proper  explora- 
tions are   made. 

Treatment. — The  treatment  of  habitual  regurgitation  is 
both  general  and  local.  Any  associated  trouble  should  re- 
ceive attention,  and  an  attempt  should  be  encouraged  to 
break  the  habit  by  force  of  will  and  by  its  voluntary  sup- 
pression. The  general  health  should  be  improved,  and  the 
nervous  system  particularly  should  be  strengthened  by 
hygienic  and  physical  remedies.  The  bromids  may  prove  to 
be  of  some  value.  Strychnin  is  more  trustworthy.  Intragas- 
tric faradization  is  beneficial,  or  cervicogastric  galvanization 
may  be  employed,  particularly  when  the  regurgitation  is  due 
to  insufficiency  of  the  cardia.  More  important  is  the  regula- 
tion of  the  diet,  selecting  those  articles  of  food  which  leave 
the  stomach  earliest  and  excite  its  functions  least.  All  the 
food  should  be  most  minutely  divided.  Constipation,  rapid 
eatintr,  and  fatigfue  increase  the  trouble. 


Vll.  RUMliNATlON,  OR  MERYCISM. 

Rumination  is  a  motor  disorder  of  the  stomach  character- 
ized by  the  easy,  quiet,  effortless,  sometimes  voluntary,  some- 
times involuntary,  regurgitation  into  the  mouth  of  food  which 
is  (according  to  its  taste  and  to  the  mental  peculiarities  of  the 
patient)  at  times  spit  out,  and  at  times  reswallowed  after  a 
second  mastication,  which,  instead  of  exciting  disgust,  is 
performed  with  pleasure.  Pyrosis,  regurgitation,  and  rumina- 
tion differ  more  in  degree  than  in  nature — out  of  the  volun- 
tary act  the  habitual  and  involuntary  may  develop.  Remas- 
tication  is  a  distinctive  and  essential  characteristic  of  rumina- 
tion, but  it  is  not  present  at  all  times  in  a  particular  case.    In 


THE   MOTOR  DYNAMIC  AFFECTIONS.  323 

merycism  man  really  "chews  the  cud,"  as  do  the  rumi- 
nants, but  only  a  part  of  the  food  regurgitated  may  be 
remasticated  and  swallowed,  the  remainder  being  spit  out ;  or 
remastication  may  be  only  occasionally  performed.  It  is  the 
second  mastication  of  the  food  which  distinguishes  rumina- 
tion from  reei-irgitation,  and  without  its  detection  the  exist- 
ence  of  the  affection  can  not  be  established.  Habitual  regur-. 
gitation  may  be  just  as  obstinate  and  persistent. 

Pathogenesis. — Various  explanations  of  the  nature  of 
rumination  have  been  given.  It  has  been  supposed  to  be  due 
to  paresis  of  the  cardia ;  but  the  deglutition  sounds  are  nor- 
mal, the  gas  and  air  do  not  escape  when  the  stomach  is  in- 
flated, and  it  is  hardly  probable  that  the  cardia  is  paretic 
while  the  rest  of  the  stomach  is  normally  or  excessively 
active,  or  that  it  can  be  made  paretic  by  irritation.  The  re- 
gurgitation has  been  explained  as  being  produced  by  irritation 
of  the  vagus  (periphery  or  center)  and  by  the  active  opening 
of  the  cardia  through  Openchowski's  dilator  fibers  of  the 
cardia ;  or  by  reflex  relaxation  of  the  cardia ;  or  it  has  been 
supposed  to  be  produced  in  the  same  manner  as  voluntary 
belching.  It  would  seem  at  times  that  the  regurgitation  is  an 
uncontrollable  habit,  which  was  voluntary  in  its  beginning. 

This  motor  dynamic  affection  of  the  stomach  occurs  in  all 
sorts  and  conditions  of  men.  It  is  very  frequent  among 
idiots  and  the  insane.  Indeed,  the  remastication  without 
shame  and  with  even  positive  enjoyment  presupposes  a 
certain  degree  of  mental  weakness.  The  ancients,  not  with- 
out some  show  of  shrewdness,  supposed  that  a  remasticating 
man  had  in  some  way  become  possessed  of  the  nature  and 
instincts  of  the  cud-chewing  animals.  Rapid  eating,  habitual 
regurgitation,  and  imitation  are  occasions  of  the  ruminating 
habit.  The  motor  function  of  the  stomach  becomes  subser- 
vient to  a  perverted  head.  It  often  stands  in  close  relation 
with  the  mental  affection,  developing  and  declining  with  it 
and  disappearing  during  lucid  intervals.  Merycism  is  more 
frequent  in  men  than  in  women,  and  may  or  may  not  be 
associated  with  other  diseases  of  the  stomach. 

Clinical  Description. — The  regurgitation  is  confined  to  the 
period  of  gastric  digestion.  During  the  period  of  repose  it 
is  rare  that  the  gases  and  the  small  quantity  of  secretions  in 
the  stomach  are  voluntarily  or  involuntarily  brought  up  into 
the  mouth.  Water  or  coffee  taken  into  an  empty  stomach 
is  not  regurgitated,  but  wine,  beer,  and  other  alcoholic 
drinks  are  frequently  brought  up  and  reswallowed.  This 
rule  is,  however,  not  without  exceptions.     The  regurgitation 


324  DISEASES  OF  THE  STOMACH. 

is  often  selective,  tlie  unmasticated  solids  being  usually 
brought  up — making  plausible  the  opinion  of  one  of  our 
patients  who  spoke  of  rumination  as  a  "  beautiful  provision 
of  nature  for  the  protection  of  the  digestive  organs  against 
rapid  eating."  The  regurgitation  occurs  without  noise,  effort, 
or  discomfort,  and  the  remastication  continues  as  long  as  the 
contents  of  the  stomach  have  a  pleasant  taste. 

The  procedure  usually  begins  immediately  after  the  meal, 
and  is  continued  as  long  as  any  pleasure  or  supposed  advan- 
tage is  derived  from  it.  The  regurgitated  food  is  either  spit 
out  or  resvvallowed  as  soon  as  it  is  perceived  to  be  sour  or 
unpalatable.  Consequently,  remastication  is  most  frequent 
during  the  first  half  hour  of  digestion,  but  may  continue 
longer  or  begin  later,  particularly  where  secretion  is  inactive 
and  the  food  eaten  is  such  as  remains  long  in  the  stomach. 

The  body  is  usually  well  nourished,  but  emaciation  occurs, 
and  may  become  extreme  where  much  of  the  regurgitated 
food  is  not  resvvallowed.  The  state  of  nutrition  is  largely 
dependent  on  the  functional  integrity  of  the  intestines,  the 
meats  and  albuminous  foods  being  often  imperfectly  digested 
by  the  stomach  in  rumination.  Salivary  digestion,  on  the 
other  hand,  is  unusually  active. 

The  duration  of  the  affection  is  indefinite,  sometimes 
beginning  suddenly  and  unexpectedly  ceasing,  sometimes 
intermittent,  but  more  frequently  obstinate  and  persistent 
from  early  youth  to  old  age. 

Rumination  may  occur  independently  or  may  be  associated 
with  other  diseases  of  the  stomach.  It  usually  ceases  when 
a  painful  affection  or  a  severe  disease  of  the  stomach  de- 
velops, and  the  gastric  symptoms  which  follow  its  disappear- 
ance are  due,  not  to  the  suppression  of  the  rumination,  but 
to  the  disease  of  the  stomach  which  caused  its  cessation.  In 
one  of  our  cases  it  ceased  with  the  sudden  development  of 
pyloric  incontinence  following  a  heavy  financial  loss.  Hydro- 
chloric acidity  may  be  normal,  increased,  or  diminished,  and 
delayed  hyperchlorhydria  is  frequent  ;  the  evacuation  of  the 
stomach  may  be  normal,  delayed,  or  too  rapid.  There 
appears  to  be  no  fixed  relation  between  rumination  and  the 
states  of  secretion  and  of  the  motor  function.  The  stomach 
may  be  normal  in  size,  enlarged,  or  very  small.  In  a  case  of 
the  authors'  the  stomach  was  very  small,  holding  about  twelve 
ounces  when  full,  indistensible,  the  greatest  transverse  diam- 
eter being  about  2^  inches.  The  mucous  membrane  was 
atrophied.  The  patient  had  ruminated  persistently  for  fifty 
years.     In    still    another  case  the   rumination  began  farther 


THE   MOTOR  DYNAMIC  AFFECTIONS.  325 

back  than  the  memory  of  the  aged  patient  could  go,  and  the 
rumination  suddenly  ceased  two  years  before  the  death  of 
the  patient,  which  was  due  to  a  disseminated  hard  cancer 
that  converted  the  pylorus  into  an  incontinent  ring  or  open 
canal. 

Rumination  has  one  pathognomonic  sign — the  remastica- 
tion  of  the  regurgitated  food.  It  is  always  digestive,  which  is 
not  true  of  esophageal  regurgitation.  In  habitual  gastric 
regurgitation  and  in  vomiting  the  food  is  never  remasticated. 
The  beastly  enjoyment  of  cud-chewing  is  definitive,  and 
without  this  sign  habitual  regurgitation  and  rumination  can 
not  be  differentiated.  In  merycism  the  regurgitated  food,  on 
account  of  its  unpleasant  taste,  may  be  spit  out  or  reswallowed. 

Treatment. — The  treatment  of  rumination  is  sometimes 
successful.  The  patient  should  be  persuaded,  if  possible,  of 
the  disgusting  unnaturalness  of  the  habit,  and  the  will 
should  be  engaged  in  an  effort  to  suppress  the  regurgitation 
or  to  reswallow  immediately  the  regurgitated  food  without 
a  second  mastication.  Thorough  mastication  of  the  food 
and  the  selection  of  a  diet  that  rapidly  leaves  the  stomach 
are  prophylactic  measures.  The  administration  of  hydro- 
chloric acid,  or,  in  suitable  cases,  of  alkalies,  may  be  beneficial. 
Strychnin  and  quinin  destroy  the  insane  delight  of  remasti- 
cation,  and  may  be  used  if  they  will  induce  the  patient  to 
reswallow  the  regurgitated  bitter  food.  Electricity  and 
strychnin  may  be  employed  in  the  treatment  of  the  second- 
ary paresis  of  the  cardia  and  the  secondary  dilatation  of  the 
lower  part  of  the  esophagus  which  sometimes  exist. 


Vlll.    NERVOUS  VOMITING. 

Every  act  of  vomiting  is  nervous,  but  the  incrimination  of 
the  nervous  system  would  be  manifestly  unjust  when  it  is 
responding  to  excitation  in  a  normal  manner.  Vomiting  as  a 
dynamic  affection  of  the  stomach  is  not  only  produced  by  the 
nervous  system,  but  is  also  the  expression  of  a  particular 
state  of  the  nerve-centers  that  govern  the  movements  of  the 
stomach.  From  the  influences  of  these  centers  on  the  vom- 
iting center  located  in  the  medulla  result  the  co-ordinated 
contractions  of  the  voluntary  muscles  concerned  in  the  pro- 
duction of  the  overt  act. 

The  vomiting  center  is  supposed  to  be  represented  by  a 
distinct  nucleus  of  one  of  the  roots  of  the  vagus,  and  is  in 
close  eccentric  relation  with  the  centers  that  transmit  motor 


326  DISEASES  OF  THE  STOMACH. 

impulses  to  the  muscles  of  the  thorax,  abdomen,  diaphragm, 
larynx,  pharynx,  esophagus,  and  stomach.  Through  this 
center  the  complex  act  of  vomiting  is  excited  and  performed. 
The  contracted  abdominal  muscles  and  diaphragm  compress 
the  stomach.  The  stomach,  particularly  the  pyloric  part, 
contracts,  antiperistalsis  begins,  the  pj'lorus  closes,  the  cardia 
opens,  the  esophagus  is  shortened  by  contraction  of  its  longi- 
tudinal fibers,  the  glottis  is  closed,  the  pressure  is  removed 
from  the  esophagus  by  expansion  of  the  thorax,  the  soft 
palate  shuts  off  the  rhinopharynx,  and  the  contents  of  the 
stomach  are  forced  in  successive  streams  through  the  mouth. 
All  these  parts  are  not  essential  to  vomiting.  The  stomach 
may  be  passive,  as  in  gastroplegia.  The  pylorus  may  be 
open,  as  in  pyloric  incontinence.  Vomiting  may  be  effortless, 
and  may  occur  at  the  end  of  expiration  and  before  either  the 
glottis  or  the  rhinopharynx  is  closed.  It  may  occur  in  spite 
of  strong  voluntary  effort  to  suppress  it.  But,  however  per- 
formed, the  act  is  excited  and  controlled  by  the  center  of 
vomiting  in  the  medulla. 

Very  complex  indeed  are  the  relations  of  this  center  to  the 
various  parts  of  the  organism,  and  correspondingly  numerous 
are  the  causes  of  its  activit>\  It  may  be  directly  irritated  by 
disease  of  the  medulla,  or  indirectly  by  disease  of  associated 
cerebrospinal  centers,  by  an  abnormal  blood  or  blood-supply, 
and  by  impressions  reflected  from  various  organs.  All  these 
forms  of  vomiting  are  symptomatic,  and  must  be  excluded 
before  the  diagnosis  of  nervous  vomiting  can  be  made. 

I.  SV.N\PTO.n.ATIC  VOMITING. 

Ce)itral  Vomiting. — The  morbid  causes  of  central  vomiting 
may  be  located  in  the  brain,  medulla,  or  cord  and  in  their 
membranous  or  bony  coverings.  It  is  a  common  symptom  of 
meningitis,  embolism,  thrombosis,  apoplexy,  abscess,  trau- 
matism of  the  brain,  h\'drocephalus,  and  cerebral  tumors. 
The  last  is  one  of  the  common  causes  of  cerebral  vomiting. 
Irritative  lesions  of  the  medulla  and  exophthalmic  goiter, 
multiple  sclerosis,  compression  myelitis,  and  particularly 
tabes  dorsalis,  may  also  produce  it.  In  all  cases  of  recur- 
ring or  persistent  vomiting  without  apparent  cause  the  signs 
of  organic  disease  of  the  central  nervous  s\'stem  should  be 
diligently  sought,  and  an  ophthalmoscopic  examination  should 
be  made. 

Hematogenous  Vomiting. — The  activity  of  the  vomiting 
center  may  be  e.xcited  by  a  deficiency  of  blood  or  by  toxemia. 


THE   MOTOR  DYNAMIC  AFFECTIONS.  327 

Anemia,  fainting,  and  prostration  are  sometimes  accompanied 
by  vomiting.  Tobacco,  opium,  chloroform,  ether,  and  other 
narcotics  exert  a  toxic  action  on  the  medulla,  as  do  also 
forms  of  uremia,  of  sepsis,  and  of  intestinal  auto-intoxica- 
tion. The  sudden  entrance  of  bacterial  poisons  into  the 
system  may  also  excite  vomiting,  and  in  this  respect  the 
poisons  of  cholera,  of  malaria,  and  of  scarlet  fever  seem  to 
be  particularly  active.  Vomiting  should  not  be  called  ner- 
vous until  these  causes  have  been  excluded. 

Reflex  Vomiting. — Reflex  vomiting  is  the  most  common 
form  and  is  produced  by  a  very  large  number  of  diseases  of 
the  various  organs.  It  is  a  symptom  of  disease  of  the  laby- 
rinth and,  rarely,  of  the  middle  ear.  Nasal  and  pharyngeal 
tumors  may  cause  it.  It  is  quite  common  in  whooping-cough 
and  in  laryngeal  tuberculosis.  Disease  of  the  lungs,  and, 
more  rarely,  of  the  pleura,  may  cause  it;  it  is  sometimes  very 
obstinate  in  pneumonia,  and  it  is  almost  a  clinical  axiom  that 
one  who  coughs  after  eating  and  vomits  after  the  coughing 
is  a  consumptive;  but  the  most  frequent  sources  of  reflex 
vomiting  are  the  abdominal  organs.  The  diseases  of  the 
stomach  need  only  be  mentioned.  Cholelithiasis  is  often  an 
obscure  cause.  Nephritis,  pyelitis,  calculus,  and  displacement 
of  the  kidney  should  not  be  forgotten.  Pregnancy  and  dis- 
eases of  the  uterus  and  its  appendages  are  frequent  causes 
of  reflex  vomiting  in  women.  The  diseases  of  the  intestines 
probably  produce  vomiting  even  more  frequently  than  those 
of  the  stomach  itself.  Among  these  may  be  mentioned  en- 
teritis, colitis,  appendicitis,  ulcer,  obstruction,  constipation, 
neoplasms,  and  intestinal  worms.  Peritonitis  is  still  another 
abdominal  cause  of  reflex  vomiting. 

Before  the  diagnosis  of  purely  nervous  vomiting  is  made, 
the  diseases  of  which  vomiting  is  a  symptom  should  be  ex- 
cluded as  far  as  possible  by  a  thorough  and  complete  exami- 
nation. And  if  such  disease  be  discovered,  the  diagnosis  is 
not  sure,  for  the  question  whether  vomiting  is  an  associated 
dynamic  affection  or  a  symptom  of  an  associated  disease  of 
the  stomach  remains  to  be  answered. 


2.    Nervous  Vomiting. 

Nervous  vomiting  as  a  dynamic  affection  occurs  in  three 
distinct  clinical  forms — hysterical,  psychic,  and  periodical. 

Hysterical  vomiting  is  rarely  encountered  except  in  the 
female  sex,  and  is  very  variable  in  its  clinical  characters. 
Occasionally,  the  nervous  vomiting  is  the  only  manifestation 


328  DISEASES  OF  THE  STOMACH. 

of  the  hysteria,  or  it  may  follow  or  alternate  with  other 
sym})toiiKs  of  this  protean  affection.  Its  nature  is  often 
revealetl  by  the  conduct  of  the  patient  (posing,  longing  for 
sympathy  or  for  attention,  perfect  freedom  from  anxiety),  by 
the  irregularity  of  its  occurrence,  and  by  its  peculiarities  in 
regard  to  the  quality  and  quantity  of  the  food.  It  is  alway.s 
digestive  and  the  vomit  is  always  alimentary.  It  comes  and 
goes  intermittently  without  evident  cause.  Only  solids,  or 
only  liquids,  or  only  a  particular  food  may  be  vomited. 
There  is  no  other  discoverable  disease.  The  evacuation  of 
the  stomach  is  ordinarily  incomplete,  and  there  may  be  but 
slight  loss  of  weight  and  strength. 

A  more  common  form  of  hysterical  vomiting  is  associated 
with  inactivity  of  all  the  vegetative  functions.  Less  oxygen 
is  consumed,  less  carbonic  acid  exhaled,  and  less  heat  is 
formed  than  in  health.  The  skin  is  dry.  The  quantity  of 
urea  and  of  all  the  other  excrementitious  constituents  of  the 
urine  eliminated  during  the  twenty-four  hours  is  notably 
diminished.  There  may  be  almost  complete  anuria.  The 
nervous  symptoms  of  uremia  are  absent,  and  there  are  no 
signs  of  disease  of  the  kidneys  and  no  obstruction  of  the 
ureters.  The  body,  in  spite  of  the  vomiting  and  of  the 
apparently  serious  insufficiency,  remains  well  nourished,  on 
account  of  the  inhibition  of  nutritive  exchange.  There  may 
be  urea  or  ammonia  in  the  vomit,  the  gastric  intolerance  may 
be  complete,  but  the  system  shows  no  other  signs  of  self- 
poisoning.  The  trouble  may  last  for  days,  and  may  disappear 
as  suddenly  and  unexpectedly  as  it  began,  or  may  be  followed 
by  other  hysterical  manifestations. 

Psychic  vomiting  is  the  most  common  of  the  tiiree  clinical 
forms  of  the  dynamic  affection,  and  is  either  mild  or  severe. 
It  is  usually  the  result  of  emotive  shock  or  of  mental  over- 
work— intense  fright,  anxiety,  sudden  misfortune.  It  is  most 
frequent  among  pale  and  overworked  school-children,  but 
may  be  encountered  in  all  walks  of  life  and  in  all  occupa- 
tions. It  sometimes  affects  men  suddenly  thrust  into  respon- 
sible positions. 

In  the  mild  form  more  or  less  of  the  food  eaten  is  periodic- 
ally vomited,  or  the  incomplete  vomiting  may  occur  after 
each  meal.  The  loss  of  food  is  not  sufficient  notably  to 
impair  nutrition.  Long  or  short  in  duration,  it  usually  ends 
suddenly  after  the  cause  has  been  removed. 

The  severe  form  is  also  characterized  b\'  alimentary  vomit- 
ing, copious  but  often  capricious.  Inanition  is  the  result  of 
the  inability  to   retain   sufficient  food,  and,  exceptionally,  the 


THE   MOTOR  DYNAMIC  AFFECTIONS.  329 

disease  may  be  fatal.  But  an  intercurrent  disease  usually  cuts 
the  thin-spun  thread  before  death  from  starvation  occurs.  The 
uncontrollable  vomiting  and  the  resulting  inanition  are  the 
only  symptoms,  the  disease  getting  its  name  from  its  mode 
of  origin. 

Periodical  vomiting  is  a  rare  but  a  sever'e  form  of  the 
dynamic  affection.  It  is  characterized  by  periodical  attacks 
of  complete  gastric  intolerance,  which  are  separated  by  in- 
tervals of  perfect  health.  The  intervals  in  the  same  case  are 
always  of  nearly  the  same  length,  during  which  time  no 
disease  of  the  nervous  system  nor  of  the  stomach  nor  of  any 
other  organ  can  be  recognized.  Theattacks  represent  periodi- 
cal breaks  in  the  course  of  good  health,  and  begin  and  end 
suddenly  and  in  an  apparently  causeless  manner.  The  dura- 
tion of  the  interval  is  from  several  days  to  several  months, 
and  that  of  the  attack  from  several  hours  to  several  days,  but 
both  the  interval  and  the  attack  have  a  definite  and  constant 
duration  in  each  particular  case. 

The  disease  begins  with  vomiting,  frequently  in  the  morn- 
ing before  breakfast,  and  without  warning,  or  preceded  by 
a  slight  headache  and  gastric  discomfort,  and  sometimes 
nausea.  The  vomiting  occurs  repeatedly,  both  spontane- 
ously and  after  the  ingestion  of  food,  drinks,  or  drugs.  The 
intolerance  of  the  stomach  is  complete,  the  vomit  in  the 
beginning  consisting  of  the  contents  of  the  stomach,  and 
thereafter  of  the  secretions  of  the  stomach  and  of  the  duo- 
denum and  its  accessory  glands, — mucus,  bile,  pancreatic  and 
gastric  juice, — mixed  with  saliva  and  whatever  has  been  intro- 
duced into  the  stomach.  There  may  be  no  pain  except  that 
due  to  retching,  but  severe  cramps  sometimes  occur,  along  with 
muscular  pains  in  the  lower  extremities.  The  patient  soon  be- 
comes anxious  and  prostrated.  The  abdomen  is  depressed,  but 
the  abdominal  muscles  are  often  soft.  Beneath  lie  the  contrac- 
tured  stomach  and  intestines,  alike  intolerant  of  distention  or 
of  interference.  Constipation  is  obstinate,  and  an  enema  is 
badly  taken,  and  the  little  water  introduced  is  quickly  ex- 
pelled. The  end  of  the  attack  is  as  sudden  and  causeless  as 
its  beginning.  There  is  no  constant  nor  characteristic  dis- 
order of  gastric  secretion. 

The  periodicity  is  not  a  pathognomonic  sign,  as  vomiting 
often  occurs  periodically  as  a  sj^mptom.  Periodical  symp- 
tomatic vomiting  may  be  the  first  and  only  sign  of  locomotor 
ataxia,  or  the  expression  of  any  of  the  forms  of  central,  of 
hematogenous,  and  of  reflex  vomiting.  The  periodicity,  the 
character  and   evolution    of  the  attack,   the  absence  of  any 


330  DISEASES  OF  THE  STOMACH. 

disease  that  could  cause  tlie  vomiting,  the  intervals  of  perfect 
health,  are  the  distinctive  features.  Emaciation  is  the  result 
of  frequent  and  severe  attacks,  and  the  disease  may  be  fatal. 

The  diagnosis  of  this  rare  form  of  nervous  vomiting  should 
be  made  only  after  the  most  exhaustive  and  repeated  ex- 
aminations. Time  only  can  exclude  incipient  tabes.  The 
vomiting  of  migraine  marks  the  end  of  the  attack,  whereas 
periodical  vomiting  begins  without  warning. 

Diagnosis. — The  diagnosis  of  the  cause  and  of  the  par- 
ticular form  of  vomiting  may  be  easy  or  very  difficult.  It  is 
best  always  to  proceed  with  the  investigation  in  a  methodical 
manner.  Is  the  vomiting  due  to  a  disease  of  the  stomach  ? 
If  not,  is  the  vomiting  symptomatic  or  nervous  ?  And  if 
nervous,  what  is  the  particular  form  ? 

If  the  vomiting  is  due  to  a  disease  of  the  stomach  it  will 
be  accompanied  by  the  usual  symptoms  and  signs  of  that 
particular  disease ;  consequently,  the  clinical  history  and 
the  physical,  functional,  bacteriological,  and  anatomical  signs 
obtained  by  the  thorough  examination  of  the  stomach  may 
at  once  reveal  the  particular  disease.  Or,  in  case  the  result 
of  the  examination  is  negative,  it  remains  to  be  determined 
whether  the  vomiting  is  symptomatic  or  nervous.  But  the 
decision  is  not  to  be  based  on  the  result  of  the  examination 
of  the  stomach  only,  for  there  are  other  symptoms  and  signs 
which  positively  suggest  or  reveal  the  symptomatic  or  ner- 
vous character  of  the  vomiting.  There  may  be  subjective  and 
objective  evidences  of  disease  of  another  organ  clinically 
known  to  cause  vomiting,  having  the  same  distinctive  features 
as  the  case  under  investigation.  The  vomiting  may  occur 
easily,  painlessly,  and  without  discoverable  gastric  cause, 
when  the  stomach  is  empty;  or  may  be  dependent  on  the 
state  of  the  feelings  or  of  the  mind — in  both  of  these  condi- 
tions the  vomiting  is  not  likely  to  be  due  to  disease  of  the 
stomach.  Food  may  be  tolerated  that  is  known  to  be  borne 
with  difficulty,  or  may  be  vomited  when  it  would  be  rationally 
expected  to  agree  better  than  food  that  is  retained.  Diet 
alone,  in  symptomatic  and  nervous  vomiting,  is  likel}-  to  be 
of  little  benefit,  but  a  correct  diet  often  arrests  at  once  the 
vomiting  due  to  a  disease  of  the  stomach,  and  in  both  symp- 
tomatic and  nervous  vomiting  the  exclusively  gastric  medica- 
tion is  of  no  value.  The  indifference  of  the  patient  and  the 
maintenance  of  good  nutrition,  in  spite  of  the  absorption  of 
but  little  nutriment,  would  reveal  its  nervous  character. 

After  excluding  a  disease  of  the  stomach,  it  may  be  diffi- 
cult or  impossible  to  decide  whether  the  vomiting  is  sympto- 


THE    MOTOR  DYNAMIC  AFFECTIONS.  33  I 

matic  or  nervous.  Symptomatic  vomiting  is  caused  by  dis- 
ease, and  on  careful  examination  this  disease  can,  as  a  rule,  be 
detected.  If  the  disease  is  such  as  usually  excites  vomiting, 
if  the  gastric  disturbance  is  greatest  during  the  period  of 
functional  activity  of  the  diseased  organ,  and  if  the  vomiting 
is  benefited  by  the  proper  treatment  of  this  disease,  it  is  fair 
to  conclude  that  the  vomiting  is  symptomatic.  Nervous 
vomiting  is  always  afebrile.  Hysterical,  psychic,  and  peri- 
odical vomiting  possess  certain  clear-cut  features  that  often 
sucfeest  at  once  the  correct  diagnosis.  There  is  no  doubt 
that  nervous  vomiting,  in  the  proper  and  limited  meaning  of 
the  word,  is  much  rarer  than  is  commonly  supposed,  and 
becomes  less  and  less  frequent  as  our  methods  of  investiga- 
tion gain  in  completeness  and  precision. 

Treatment. — The  treatment  of  all  forms  of  vomiting  is 
dominated  by  three  principles — the  control  or  removal  of  the 
source  of  excessive  irritation  ;  the  prevention  of  the  action  of 
the  cause  on  the  medullary  center  of  vomiting  or  the  arrest 
of  impressions  sent  out  from  it;  and  the  maintenance  of  the 
repose  of  the  stomach.  Or,  more  briefly  stated,  the  three 
objects  of  medication  are  to  control  or  remove  the  cause,  the 
transmission,  and  the  expression.  The  treatment  of  nervous 
vomiting  is  based  on  the  same  principles. 

The  cause  of  nervous  vomiting  is  not  always  palpable,  but 
the  influence  of  the  mind  and  of  the  moral  environment  is 
often  very  evident.  The  physician  can  do  a  great  deal,  by 
gentle  authority  and  by  assuring  suggestions,  to  relieve  the 
general  demoralization.  The  hysterical  should  be  controlled 
by  a  firm  and  skilfully  directed  hand,  and  moral  and  mental 
repose  and  balance  should  be  restored  by  whatever  means  a 
knowledge  of  human  nature  will  suggest  as  most  applicable 
to  the  individual  case.  Isolation,  change  of  scene,  and  ces- 
sation of  study  are  often  necessary.  Absolute  and  continuous 
rest  in  bed  may  be  demanded  for  the  restoration  of  nervous 
strength  and  the  equalization  of  the  circulation,  and  the 
patient  should  be  kept  in  bed  at  least  during  the  attack. 
Massage,  electricity,  and  hydrotherapy,  in  forms  suitable  for 
the  particular  case,  may  often  be  employed  with  benefit.  By 
these  means  and  by  attention  to  all  the  vegetative  functions, 
the  nervous  system  may  be  given  new  vigor  and  tone  and  the 
transmission  of  the  cerebral  impulses  may  be  prevented. 

Something  may  also  be  accomplished  by  gastric  medica- 
tion. Electricity,  hydrotherapy,  and  a  proper  diet  are  our 
best  remedies.  During  the  intervals  or  during  the  best 
moments    a    simple,   nutritious,  and    mixed    diet  should    be 


332  DISEASES  OF  THE  STOMACH. 

ordered,  and  in  suitable  cases  gavage  (overfeeding  by  means 
of  the  stomacli-tiibe)  may  be  employed. 

The  foregoing  medication  is  the  basis  of  the  curative  treat- 
ment. Tlie  vomiting  itself,  however,  often  requires  palliative 
remedies. 

Menthol,  chloroform,  iodin,  and  the  bromids  are  rarely  of 
much  value.  Oxalate  of  cerium,  in  five-grain  doses  dry  on 
the  tongue,  is  trustworthy  and  sometimes  efficient.  The 
dried  alcoholic  extracts  of  coca  (three  grs.),  of  kola  (five 
grs.),  and  of  belladonna  (y^^  of  a  gr.)  sometimes  act  effi- 
ciently when  in  combination.  A  tablet  may  be  allowed  to 
melt  on  the  back  part  of  the  tongue  or  the  mixed  powder 
may  be  placed  there.  Neither  these  drugs  nor  the  oxalate 
of  cerium  act  so  efficiently  when  swallowed  with  water. 
Suppositories  of  asafetida  (five  grs.)  and  powdered  extract  of 
valerian  (three  grs.),  repeated  every  two  hours,  exert  a  very 
soothing  and  quieting  influence.  If  there  be  much  prostra- 
tion, strychnin  hypodermically  is  the  best  palliative;  or, 
if  there  be  much  excitement,  the  phosphate  of  codein  may 
be  given  hypodermically,  or  chloral  hydrate  by  rectum,  or 
morphin  may  be  at  once  used,  without  trial  of  less  trust- 
worthy remedies.  Nitroglycerin  may  be  useful  to  equalize 
the  circulation. 

Sedative  galvanization  is  a  remedy  well  worthy  of  trial  in 
the  obstinate  cases.  Large  electrodes  should  be  placed  over 
the  stomach  (anode)  and  over  the  cervical  spine,  and  a  cur- 
rent of  low  density  should  be  slowly  turned  on  and  slowly 
cut  off  after  being  allowed  to  flow  uninterruptedly  for  from 
ten  to  twenty  minutes.  Or  sedative  polar  cervicogastric 
galvanization  may  be  used,  or  even  intragastric  faradization. 

An  excellent  remedy  is  cold  or  heat  applied  to  the  spine 
and  to  the  epigastrium.  The  rubber  coils  are  most  conveni- 
ent, and  through  them  either  ice-cold  or  hot  water  may  be 
allowed  to  flow.  Heat  is  best  in  prostration  and  cold  in  ex- 
citement;  but  the  idiosyncrasy  of  the  patient  should  be  con- 
sidered. The  ether  spray  may  be  used  along  the  spine  and 
over  the  epigastrium  when  a  quick  effect  is  desired.  A  blister 
(canthos  plaster)  over  the  back  of  the  neck  and  over  the 
epigastrium  is  sometimes  accompanied  by  the  cessation  of 
the  vomiting. 

If  the  stomach  is  intolerant,  the  patient  should  be  kept 
perfectly  quiet,  in  the  recumbent  position,  and  neither  food 
nor  medicines  should  be  given  by  mouth  ;  rectal  feeding  is 
then  our  best  resource.  Hysterical  intolerance  is  often  re- 
lieved   by  the    introduction  of   the    food    into    the    stomach 


THE   MOTOR  DYNAMIC  AFFECTIONS.  333 

through  the  tube,  the  food  thus  introduced  being  generally 
retained.  In  suitable  cases  overfeeding  with  the  tube  (gavage) 
may  be  tried. 

In  the  milder  cases  the  diet  must  be  selected  by  clinical  ex- 
perimentation, there  being  in  the  absence  of  digestive  disease 
no  contraindication  to  any  food,  and  the  foods  difficult  of  di- 
gestion are  sometimes  best  borne.  Often  in  severe  attacks 
small  quantities  of  dry,  solid  food  can  be  retained  when 
liquids  are  at  once  rejected.  If  there  be  much  prostration 
the  patient  should  be  kept  strictly  and  persistently  in  the 
recumbent  position.  The  treatment,  as  it  thus  appears,  varies 
with  each  individual  case,  and  many  of  the  foregoing  reme- 
dies are  generally  applicable. 


IX.  INCONTINENCE  OF  THE  PYLORUS. 

Contrary  to  the  common  opinion,  the  pylorus  is,  in  all 
probability,  lightly  closed  during  the  period  of  repose  of  the 
normal  stomach  ;  for  gas  remains  in  the  viscus  in  spite  of  its 
retraction,  and  reflux  of  bile  and  duodenal  secretion  does  not 
occur.  The  passage  is  more  easily  forced  by  gentle  pressure 
from  the  duodenal  than  from  the  gastric  side  (Oser).  Stimu- 
lation of  the  sympathetic  relaxes,  but  that  of  the  vagus  closes 
it.  But  it  is  more  likely  that  normal  contraction  and  relaxa- 
tion of  the  pylorus  during  the  period  of  gastric  digestion 
are  automatically  regulated  through  the  ganglia  in  its  walls. 

The  pylorus  is  incontinent  when  it  is  insufficient  during 
digestion,  neither  controlling  nor  preventing  the  too  rapid 
evacuation  of  the  stomach.  The  trouble  may  be  organic  or 
functional. 

Pathogenesis. — The  organic  form  occurs  in  cancer,  ulcer, 
and  duodenal  obstruction.  Carcinoma,  particularly  scirrhus, 
may  convert  the  pylorus  into  a  rigid  tube  with  an  unob- 
structed lumen,  or  the  canal  may  be  made  by  ulceration  of 
the  neoplasm,  or  the  ring  muscle  may  be  rendered  stiff  and 
functionless  by  cancerous  infiltration.  Ulcer,  when  either 
lateral  or  circular,  may  also  destroy  the  contractility  of  the 
muscle,  or  a  cicatrix  or  a  cicatricial  band  or  adhesion  (peri- 
gastritis) may  hold  the  canal  open.  In  duodenal  stenosis,  or 
even  in  stenosis  of  the  jejunum,  the  pylorus  may  be  mechani- 
cally dilated  by  the  material  that  accumulates  above  the 
obstruction.  Gastroptosis  with  angular  constriction  of  the 
duodenum  may  be  associated  with  pyloric  dilatation.  But 
either   the    history  or  signs  of  ulcer  or  of  cancer  or  of  duo- 


334  DISEASES  OF  THE  STOMA  CI/. 

denal  obstruction  will  reveal  the  organic  nature  of  the  pyloric 
incontinence. 

Very  rarely  incontinence  of  the  pylorus  is  a  dynamic  affec- 
tion. Quite  frequently  the  stomach  empties  itself  with 
abnormal  rapidity,  but  most  commonly  on  account  of  exces- 
sive peristalsis.  When  the  rapid  evacuation  is  due  to  the 
insufficiency  of  the  pylorus,  it  is  not  prevented  by  drugs  that 
control  peristalsis. 

Clinical  Description. — Pyloric  incontinence,  except  when 
due  to  duodenal  obstruction,  is  manifested  by  a  few  symptoms 
that  maybe  somewhat  characteristic.  It  is  sometimes  noticed 
that  the  abdomen,  previously  flat,  suddenly  becomes  tympan- 
itic after  eating;  but  this  symptom  occurs  in  hysteria,  and 
may  be  explained  in  other  ways.  On  artificial  inflation  the 
stomach  does  not  fill  and  distend  and  outline  itself  on  the 
abdominal  wall,  but  with  each  pressure  of  the  bulb,  or  con- 
tenijioraneously  with  the  generation  of  carbon  dioxid,  pyloric 
bubbling  can  be  palpated  and  heard,  and  the  limitation  of  the 
stomach  by  percussion  becomes  impossible.  Eventually  the 
stomach  may  be  distended  with  the  air,  but  its  limits  can  not 
be  determined  by  percussion.  The  inflation  test  is  of  more 
value  when  it  is  made  during  digestion,  when  the  stomach  is 
easily  inflated  if  the  pylorus  is  not  insufficient ;  if  gas  bub- 
bles through  the  pylorus,  the  bubbling  occurs  in  relation 
with  the  compressions  of  the  inflating  rubber  bulb,  the  latter 
sign,  under  the  circumstances,  being  characteristic  of  pyloric 
incontinence.  In  hypermotility  inflation  is  easy  and  the  evacu- 
ation of  the  stomach  is  peristaltic.  These  positive  or  negalive 
peculiarities  of  inflation  are  distinctive  when  they  occur  with 
regularity  and  in  association  with  the  following  signs. 

The  stomach  persistently  empties  itself  too  rapidly  after 
the  test-breakfast,  after  the  test-dinner,  after  a  glass  of  milk, 
and  after  two  glasses  of  water  have  been  taken.  Contrary  to 
the  distinctions  that  exist  normally,  one  food  leaves  the 
stomach  about  as  rapidly  as  another.  As  a  consequence  of 
this  phenomenon,  lienteric  diarrhea  is  common  when  the  diet 
is  exciting  and  unsuited  to  the  intestines.  A  bland  food  like 
milk  rapidly  cures  this  particular  form  of  diarrhea.  Intuba- 
tion of  the  pylorus  is  less  difficult  than  when  the  pylorus 
normally  contracts. 

The  reflux  of  bile  and  pancreatic  juice,  as  would  naturally 
be  expected,  is  easy,  but  it  does  not  occur  constantly.  Previ- 
ous eructation,  regurgitation,  rumination,  and  vomiting  usually 
cease  when  the  pylorus  becomes  incontinent;  but  this  is  not 
always  so. 


THE   MOTOR  DYNAMIC  AFFECTIONS.  335 

Diagnosis. — The  diagnosis  is  made  by  the  foregoing  group 
of  signs  and  symptoms  in  the  absence  of  all  evidence  of  ulcer, 
cancer,  or  hypermotility.  The  trouble  is  not  dangerous,  as 
is  conclusively  proven  by  the  results  of  pyloroplasty  and 
pylorectomy. 

Treatment. — The  treatment  is  chiefly  dietetic,  such  food 
being  prepared  and  selected  as  is  readily  digested  by  the  intes- 
tines. Diarrhea  and  intestinal  colic  may  necessitate  frequent 
small  meals.  Strychnin  and  hydrastinin  may  be  of  some 
use,  but  intragastric  faradization  is  more  rational.  In  cancer 
and  ulcer  the  incontinence  of  the  pylorus  is  an  advantage. 


X.  GASTROPLEGIA. 

Paralysis  of  the  stomach  is  rare  and  has  usually  been  con- 
founded with  "dilatation."  It  is  a  distinct  affection,  charac- 
acterized  by  the  sudden  loss  of  the  contractile  power  of  the 
muscular  layer.  In  myasthenia  the  muscle  is  weak  and  has 
lost  more  or  less  of  its  normal  elasticity  and  tone.  In  gas- 
troplegia  the  muscle  is  paralyzed  and  the  power  to  contract 
is  lost.  The  stomach  is  a  motionless  sac  that  passively 
yields  to  mechanical  stretching. 

The  chief  cause  of  gastroplegia  is  traumatic  shock.  After 
an  accident,  or  particularly  after  a  laparotomy,  the  stomach 
is  found  to  be  paralyzed.  The  same  condition  may  occur  in 
hysteria  and  as  a  result  of  moral  shock  during  the  digestion 
of  a  meal.  Still  another  cause  is  acute  gastritis,  and  it  may 
occur  in  multiple  neuritis. 

The  beginning  is  sudden  and  the  duration  variable.  After 
a  few  days  the  muscle  may  gradually  regain  its  power,  or  the 
loss  of  contractility  may  be  permanent.  After  laparotomy 
and  traumatism  it  may  be  accompanied  by  collapse. 

The  chief  sign  is  absolute  gastric  retention.  Food  and 
secretions  and  gases  accumulate  in  the  stomach  and  render 
the  epigastrium  prominent.  The  distention  of  the  stomach 
is  painful,  and  the  contents  are  often  partly  removed  by 
expression  and  by  overflow  through  the  pylorus. 

The  stomach  should  be  kept  clean  and  empty  by  lavage 
and  the  body  should  be  nourished  by  rectum.  A  part  of 
the  treatment  is  that  of  shock  and  of  the  causative  disease — 
hysteria,  peritonitis,  neuritis,  etc.  The  ordinary  means  should 
be  employed  to  restore  the  paralyzed  muscle  or  prevent  its 
atrophy.  The  sovereign  remedy  of  traumatic  gastroplegia 
is  strychnin,  administered  hypodermically  in  large  doses. 


336  DISEASES  OF  THE  STOMACH. 


CHAPTER  IV. 
NEURASTHENIA  GASTRICA. 

Neurasthenia  {>eupov,  nerve,  and  aaOtvda,  weakness)  gastrica 
is  a  dynamic  affection  characterized  by  excessive  irritability 
and  marked  weakness  of  the  nerves  which  supply  the  stomach, 
branches  of  the  pneumogastric  and  of  the  solar  plexus.  It 
is  a  particular  kind  of  morbid  sensibility  of  the  stomach, 
developing  in  a  fit  constitution  after  the  excessive  expen- 
diture of  nerve  force.  It  is  digestive  discomfort  without 
noteworthy  modification  of  the  process  of  digestion  and 
without  an  anatomical  lesion  of  the  mucous  membrane. 

Gastric  neurasthenia  is  not  limited  to  the  cases  where  the 
uncomfortable  sensations  and  the  other  symptoms  of  which 
the  patient  complains  are  referred  to  the  stomach.  The  mani- 
festations of  the  irritable  weakness  of  the  nerves  supplying 
the  stomach  may  occur  in  distant  parts  of  the  body.  It  is 
not  the  localization  of  the  expression,  but  that  of  the  weak 
and  genetic  point  which  defines  the  affection.  It  is  essen- 
tially a  dynamic  sensory  affection,  and,  more  definitely,  an 
affection  chiefly  of  the  abdominal  sympathetic. 

The  solar  plexus,  receiving  all  the  impressions  from  the 
abdominal  and  thoracic  organs,  is  very  intimately  associated 
with  the  cerebrum.  Through  it  sensation,  thought,  and  emo- 
tion influence  digestion.  Through  it  and  the  pneumogastric 
nerves  digestion  affects  the  activity  of  the  brain.  Through 
it  most  of  the  distant  nervous  symptoms  of  the  diseases  of 
the  stomach  are  transmitted.  It  is  the  connecting  link  be- 
tween the  moral,  the  intellectual,  and  the  vegetative  life. 
And  this  is  best  seen  not  in  health,  when  its  working  is  silent 
and  invisible,  not  in  experimentation,  when  its  action  is  imper- 
ceptible or  unphysiological,  but  in  disease,  when  its  morbid 
action  rises  into  consciousness  and  is  expressed  by  certain 
symptoms  and  signs.  It  is  this  highest  and  greatest  assem- 
blage of  sympathetic  centers  which  unites  the  nervous  symp- 
toms of  neurasthenia  gastrica. 

Strictly  localized  in  the  beginning,  the  irritable  weakness 
extends  to  the  connected  cerebral  and  spinal  centers,  or, 
originating  in  them,  secondarily  affects  the  solar  plexus.  The 
vicious  circle  thus  becomes  established.     The  clinical  picture 


NEURASTHENIA    GASTRICA.  337 

varies  accordingly  as  the  cerebrospinal  or  abdominal  centers 
control  the  generation  of  the  manifestations  ;  but  even  when 
the  gastric  symptoms  predominate,  their  variation,  with  the 
mental  and  moral  changes,  may  be  easily  observed. 

The  peculiar  discomfort  of  neurasthenia  gastrica  is  not  due 
to  any  anatomical  lesion  of  the  mucosa,  and  is  out  of  all  pro- 
portion to  the  disturbance  of  the  digestive  functions.  This 
is  one  of  its  cardinal  and  distinctive  characteristics.  Not  all 
gastric  symptoms  are  neurasthenic — not  even  when  they  are 
of  the  same  character  and  grouping  as  in  this  affection. 
Digestion  often  becomes  uncomfortably  perceptible  in  other 
diseases,  but  the  effect  stands  in  a  natural  proportion  to  its 
cause.  When  the  irritation  is  abnormal  a  corresponding 
effect  should  naturally  follow.  The  harmony  is  preserved 
between  the  activity  of  the  external  cause  and  the  intensity 
of  perception.  In  neurasthenia,  on  the  other  hand,  this  har- 
mony is  lost,  and  the  effect  is  many  times  multiplied.  The 
nerve-centers  are  feverishly  active.  The  perceived  and  actual 
effect  is  excessive — too  intense  and  too  prolonged.  While 
the  action  is  excessive,  the  total  energy  is  less ;  but  the  ex- 
cessive action  is  not  sufficient  to  produce  gastric  spasm,  nor 
does  the  weakness  amount  to  paresis.  Secretion  may  remain 
normal,  the  mechanical  work  may  be  efficient,  or  both  may 
be  excessively  active — but  digestion  rises  painfully  into  con- 
sciousness. Secretion  may  diminish  slightly,  the  motor  func- 
tion become  insufficient,  or  both  may  continue  needlessly  long 
— still  digestion  is  distressing.  The  patients  suffer,  be  the 
evolution  of  digestion  normal,  hastened,  or  delayed.  The  want 
of  harmony  between  cause  and  effect  exists ;  the  impressions, 
normally  unfelt,  are  multiplied  and  built  up  into  conscious 
sensations  on  account  of  the  irritable  weakness  of  the  nerve- 
supply  of  the  stomach. 

Etiology. — Neurasthenia  gastrica  is  common  in  both  sexes 
during  adult  and  middle  life.  A  large  number  of  the  cases 
occur  among  students,  musicians,  and  teachers,  and  among 
those  on  whom  the  cares  of  life  and  the  reverses  of  for- 
tune have  fallen  heavily.  Worry  and  overwork  lay  the 
foundation  for  a  majority  of  the  cases.  Prolonged  and  ex- 
cessive expenditure  of  nerve  force,  particularly  by  sexual 
excesses  and  abuses,  and  by  unsatisfied  sexual  excitement, 
exhausts  and  overexcites  in  a  marked  manner  the  abdominal 
sympathetic. 

The  irritable  weakness  of  the  nerve-supply  of  the  stomach 
may  be  developed  in  a  number  of  ways.  A  nervous  tem- 
perament and  constitution,  inherited  or  acquired,  predispose 


338  DISEASES  OF  THE   STOMACH. 

to  it.  Neurasthenia  gastrica  is  often  associated  as  cause  and 
effect  witli  general  neurasthenia.  The  exhausting  and  irri- 
tating impressions  may  come  from  the  brain  or  may  be 
reflected  from  other  organs.  The  neurasthenia  maybe  partly 
caused  by  a  blood  state,  as  uricemia,  uremia,  diabetes,  auto- 
intoxication, or  by  a  blood  disease.  The  anatomical  diseases 
of  the  stomach  often  produce  it,  but  it  is  then  only  secondary 
and  symptomatic,  and  not  a  distinct  affection.  The  excita- 
tions which  occasion  the  outbreak  when  the  nervous  system 
is  already  weak  may  originate  in  the  mucous  membrane  of 
the  stomach,  from  irritant  foods,  drinks,  and  drugs;  but  the 
most  important  factors  in  the  genesis  of  neurasthenia  gas- 
trica, in  our  experience,  are  disease  of  the  intestines,  sexual 
excesses,  self-abuse,  worry,  and  overstudy. 

Clinical  Description. — All  the  symptoms  of  neurasthenia 
gastrica  are  referable  to  the  irritable  weakness  of  the  nerve- 
supply  of  the  stomach.  These  nerves  and  their  centers  may 
be  alone  involved,  and  may  produce  the  whole  clinical  picture, 
or  they  may  be  affected  in  common  with  the  general  nervous 
system,  and  may  directly  cause  only  a  part  of  the  manifesta- 
tions. In  four-fifths  of  the  cases  of  all  forms  of  neurasthenia 
the  gastric  symptoms  become  prominent  at  some  moment  in 
its  evolution.  So  frequently  do  the  symptoms  of  neurasthe- 
nia, be  the  affection  primary  or  secondary,  cluster  about  the 
solar  plexus. 

The  affection  is  variable  in  its  severity  and  in  its  evolution. 
The  course  maybe  intermittent,  remittent,  or  stationary;  or  it 
may  rapidly  progress  from  a  very  mild  beginning  to  a  mental, 
moral,  physical,  and  nutritive  state  sufficiently  severe  to 
excite  alarm.  In  the  mild  cases  the  patients  are  only  diseased 
because  they  complain,  there  being  no  objective  signs  of 
trouble.  The  nutrition,  strength,  and  appearance  of  health  are 
preserved,  the  digestion  and  utilization  of  food  are  normal, 
all  the  organs,  including  the  stomach,  perform  their  functions 
physiologically.  The  affection  may  be  purely  subjective,  the 
patients  searching  in  vain  for  words  strong  enough  to  des- 
cribe their  sensations  and  to  persuade  others  of  the  reality  of 
their  sufferings.  In  the  very  severe  cases,  however,  the  ob- 
jective signs  may  alarm  the  physician.  Emaciation  and  loss 
of  strength  may  suggest  a  severe  anatomical  disease.  The 
appetite  may  be  lost,  the  diet  restricted  and  insufficient,  insom- 
nia obstinate,  and  the  secretory  and  motor  functions  of  the 
stomach  and  intestines  may  be  depressed.  The  subnutrition 
is  the  result  not  of  an  insufficient  diet  alone,  but  of  the  influ- 
ence of  the  peculiar  discomfort  and  of  the  mental,  moral,  and 


NEURASTHENIA    GASTRIC  A.  339 

physical  state  of  the  patient  on  the  functions  of  the  stomach. 
Between  the  mild  and  the  severe  cases  all  grades  of  the  affec- 
tion exist,  some  simple  and  o^thers  complicated. 

The  symptoms  differ  during  the  period  of  digestion  and  the 
period  of  gastric  repose,  are  markedly  influenced  by  the  men- 
tal and  moral  state,  are  commonly  associated  primarily  and 
eventually  with  some  of  the  signs  of  general  neurasthenia, 
and  the  suffering,  shorn  of  all  acuteness,  is  moderate,  unnerv- 
ing, and  sympathetic.  The  characteristic  symptoms  are  sen- 
sory, cerebral,  muscular,  and  circulatory. 

The  sensory  symptoms  are  the  hyperesthesia  and  neuralgia 
and  the  indefinable  discomfort  due  to  the  excitation  and 
irritable  weakness  of  the  abdominal  sympathetic.  During 
digestion,  and  not  rarely  when  the  stomach  is  in  repose, 
there  is  a  sensation  of  fullness,  heaviness,  or  weight.  What- 
ever touches  the  mucous  membrane — food,  gas,  drinks,  secre- 
tions, contact  of  the  two  surfaces — may  produce  distress. 
Belching  is  common,  and  the  patient  often  complains  of  a  ball 
in  the  throat  or  gullet  and  of  heartburn  which  is  due  to  an 
excess  of  neither  hydrochloric  nor  butyric  acids.  Or  the  pa- 
tient complains  chiefly  of  a  peculiar  digestive  uneasiness  and 
discomfort,  which  may  begin  as  soon  as  food  enters  the 
stomach,  or  after  a  short  period  of  exaltation  and  well-being, 
or  which  may  be  confined  to  the  period  of  free  acidity.  This 
free  acid  discomfort  may  develop  into  severe  pain,  which  is 
immediately  relieved  by  bland  nitrogenous  food  of  a  high 
acid-combining  power,  like  milk.  There  is  no  excessive 
acidity  and  the  appetite  is  not  increased,  but  often  diminished, 
thus  distinguishing  the  symptom  from  adenohypersthenia  gas- 
trica  and  bulimia.  The  skin  over  the  stomach,  both  before 
and  behind,  is  often  abnormally  sensitive.  The  hyperesthesia 
is  over  the  area  supplied  by  the  cutaneous  sensory  nerves 
connected  with  the  irritated  part  of  the  sympathetic  system. 
There  are  often  epigastric,  dorsal,  and  intercostal  neuralgia 
and  painful  pressure-points.  The  sensitive  points  correspond, 
usually,  with  the  large  sympathetic  ganglia  and  with  the  sen- 
sory branches  of  the  spinal  nerves  along  either  side  of  the 
dorsal  spine.  The  hyperesthesia  of  neurasthenia  gastrica  is 
characterized  by  its  beginning  over  the  stomach,  where  it  is 
most  constant,  and  extending  to  the  sides  and  thorax,  neck, 
and  shoulders,  and  often  to  the  head.  It  is  often  confined  to 
the  upper  part  of  the  l^ft  side  of  the  body  or  head. 

Normally,  during  the  digestion  of  a  full  meal  there  is  a 
desire  for  repose  and  isolation,  but  the  depression  of  the 
cerebral  functions  may  be  prevented  by  stimulants  like  coffee, 


340  DISEASES  OF  THE   STOMACH. 

tobacco,  and  entertaining  companionship.  Digestion  physi- 
ologically enforces  cerebral  inactivity.  But  in  neurasthenia 
gastrica  the  natural  depression  may  be  supplanted  by  a  short 
period  of  well-being,  or  may  be  immediately  followed  by  dis- 
ordered cerebral  activity  and  unhealthy  sensations.  The 
head  is  heavy  or  light,  the  thoughts  ramble,  ideas  follow  one 
another  in  disorder,  and  the  consciousness  of  this  confusion 
produces  anxiety,  gloom,  and  fear.  The  anxiety  has  no  exter- 
nal cause  and  the  fear  no  e.vternal  object — both  are  centrally 
excited.  Study  and  concentration  of  attention  and  control  of 
thought  are  difficult,  and  often  become  impossible  after  a 
short  effort.  The  mind  is  rapidly  drawn  aside  in  spite  of 
the  will.  There  is  no  repose  of  mind  or  spirit,  but  a  con- 
stant internal  unrest.  The  patient  is  made  anxious  and 
pessimistic  by  little  accidents  which  would  have  no  effect  in 
health.  The  physician's  assurance  that  there  is  no  serious 
disease  is  as  nothing  when  weighed  against  the  suffering, 
unrest,  and  utter  lack  of  energy  and  will-power.  These  cere- 
bral symptoms  are  often  accompanied  by  headache,  insomnia, 
and  vertigo,  are  worse  during  digestion,  and  subside  slowly 
after  digestion  is  finished  if  there  be  no  secondary  sources  of 
irritation. 

The  contents  of  the  stomach  irritate  the  oversensitive 
nerves  of  the  mucous  membrane,  and  these  impressions  are 
transmitted  to  the  solar  ple.xus  and  the  medulla.  From  these 
centers  the  heart's  action  and  the  vasomotor  nerves  often 
become  disturbed.  Tachycardia,  palpitation,  bruit  dc  galop, 
arrhythmia,  intermittent  pulse,  hot  flashes,  and  cold  hands  and 
feet  result.  The  involuntary  muscles  become  weak  and  irri- 
table, and  the  voluntary  muscles  may  be  easily  exhausted. 

All  these  symptoms  vary  in  their  intensity  from  day  to  day, 
and  are  rarely  all  present  in  the  same  case.  Neurasthenia 
gastrica  may  be  monosymptomatic  in  its  expression — diges- 
tive discomfort,  or  disturbance  of  the  action  of  the  heart,  or 
neuralgia,  or  pessimism,  or  headache,  or  other  cerebral  symp- 
toms. Their  intimate  relation  to  digestion  is  a  distinctive 
characteristic  of  these  neurasthenic  symptoms. 

In  some  cases  the  discomfort  and  flatulency  are  excited  by 
certain  articles  of  food,  particularly  acids  and  sweets,  in  con- 
tradiction to  the  general  rule  that  in  neurasthenia  gastrica 
one  food  is  digested  about  as  comfortably  as  another — no 
better  and  no  worse.  Guided  by  experience,  one  food  is 
excluded  after  another,  until  some  patients  become  meat 
eaters,  or  vegetarians,  or  half  starve  themselves. 

The  functions  of  the  intestines  are  rarely  normal  in  neuras- 


NEURASTHENIA    GASTRICA.  34I 

thenia  gastrica,  because  the  whole  abdominal  sympathetic  is 
often  in  the  same  state  of  irritable  weakness  as  the  solar 
plexus  and  the  ganglia  in  the  gastric  wall.  The  abdomen  is 
sometimes  sunken  and  the  intestines  contracted  and  empty, 
particularly  in  the  severe  form  with  subnutrition.  Sometimes 
there  is  nervous  diarrhea,  sometimes  general  gaseous  disten- 
tion of  the  intestines  ;  but  the  most  characteristic  condition 
is  localized  contractions  and  isolated  gaseous  distention  of 
individual  knuckles  of  the  intestines.  The  most  frequent  sites 
of  this  gas  accumulation  are  in  the  cecum,  the  lower  end  of 
the  ileum,  and  in  the  transverse  colon  near  the  splenic  flexure. 
The  patient  complains  of  the  gas  remaining  still,  not  easily 
passing  either  up  or  down.  These  distended  knuckles  are 
always  tender,  and  the  gas  gurgles  under  moderate  pressure 
and  does  not  return  to  the  point  after  the  removal  of  the 
pressure.  After  the  gas  is  pressed  out  the  tenderness  disap- 
pears. Massage  restores,  in  this  condition,  the  normal  peri- 
staltic flow  of  the  contents  more  rapidly  and  efficiently  than 
in  any  other  intestinal  affection,  and  is  of  great  utility  in 
relieving  the  radiated  nervous  symptoms  and  in  establishing 
the  diagnosis. 

In  the  majority  of  the  cases  of  neurasthenia  gastrica  secre- 
tion is  normal,  but  in  the  remainder  of  the  cases  the  acid, 
and  rarely  the  ferment,  secretion,  may  vary  slightly  from  the 
normal.  There  is,  exceptionally,  mild  supersecretion  ;  there  is 
more  frequently  simple  diminution  of  secretion,  as  more  or 
less  all  of  the  organic  functions  are  in  abeyance.  But  the 
most  frequent  variation  of  secretion  is  a  disorder  of  its  evolu- 
tion. It  is  often  normal  for  a  short  period  (during  the  first 
twenty  to  forty  minutes  after  the  test-breakfast),  and  thereafter 
is  insufficient,  constituting,  when  the  examination  of  the  con- 
tents is  made  only  at  the  end  of  one  hour,  one  group  of  the 
cases  with  diminished  activity.  In  another  group  of  cases 
the  evolution  of  secretion  is  delayed,  and  acid  first  remains 
free  after  more  than  an  hour  has  passed.  There  is  no  per- 
ceptible diminution  of  ferment  secretion,  unless  there  be  sub- 
nutrition.  In  adenasthenia  gastrica,  on  the  other  hand,  which 
is  an  independent  dynamic  affection,  secretion  of  the  acid,  and 
often  of  the  ferments,  is  deficient  throughout  the  period  of 
digestion,  and  there  is  none  of  the  peculiar  discomfort  and 
irritable  unrest.  The  disorders  of  secretion  are  neither  per- 
sistent nor  characteristic,  and  are  in  probability  caused  by 
vasomotor  disturbances. 

In  neurasthenia  gastrica  the  stomach  usually  empties 
itself  within  the  normal  period,  and  the  motor  function  has 


342  DISEASES  OF  THE  STOMACH. 

consequently  been  supposed  to  be  normal  ;  but  this  is  not 
always  a  just  conclusion.  The  stomach  is  often  tonically,  but 
not  painfully,  contracted.  Swallowed  air  accumulates  in  it, 
and  is  often  only  got  rid  of  by  belching,  the  cardia  yield- 
ing before  the  firmer  pylorus.  If  the  accumulated  air  does 
not  escape,  it  may  eventually  cause  anxiety,  shortness  of 
breath,  palpitation,  and  sometimes  a  sense  of  impending 
death.  The  stomach,  on  physical  examination,  is  then  found 
contracted  on  the  contained  air,  which  can  not  be  expelled 
by  pressure ;  but  after  proper  massage  for  a  short  time  it 
escapes  into  the  intestines,  with  relief  of  the  s}-mptoms.  The 
most  common  motor  disturbance,  however,  is  simple  relaxa- 
tion, with  splashing  during  the  digestive  period.  Its  inde- 
pendence of  the  quality  and  quantity  of  the  food,  its  associa- 
tion with  the  nervous  irritable  weakness,  the  imperceptible 
delay  in  the  evacuation  of  the  stomach  resulting  from  it,  and 
the  intolerance  of  remedies  which  do  good  in  myasthenia 
gastrica,  distinguish  this  motor  disorder  of  neurasthenia  gas- 
trica  from  myasthenia,  which  is  a  distinct  dynamic  affection. 

There  are  no  anatomical  signs  of  disease,  and  no  bacterio- 
logical signs  (except  incidentally,  as  may  occur  in  the  nor- 
mal stomach).  It  should  be  remembered  that  neurasthenia 
gastrica  may  terminate  in  myasthenia  gastrica.  and  often 
becomes  associated  with  chronic  colitis,  particularly  with 
enteritis  membrnnacea. 

Differential  Diagnosis. — Whenever  the  symptom-group 
of  neurasthenia  gastrica  is  met  with  in  practice  a  most 
thorough  examination  of  the  whole  body  should  be  made. 
In  this  manner  only  can  the  idiopathic  and  secondary  forms 
be  separated.  The  signs  of  general  neurasthenia  should  be 
sought ;  the  blood  should  be  examined  for  idiopathic  anemia 
and  for  the  amceba  malariae,  and  the  urine  for  signs  of  chronic 
nephritis,  of  gout,  and  of  diabetes  ;  cholelithiasis  should  be  ex- 
cluded ;  the  genital  organs  should  be  examined  for  disease, 
and  the  intestines  examined  particularly  for  chronic  colitis. 
All  these  diseases  may  be  accompanied  by  the  digestive  dis- 
comfort and  uneasiness,  or  by  the  cerebral  symptoms  of 
neurasthenia  gastrica.  It  is  only  by  careful  exclusion  and  by 
particular  attention  to  the  distinctive  features  of  the  symp- 
toms as  already  described  that  the  idiopathic  affection  can  be 
defined  as  a  morbid  entity. 

Some  of  the  diseases  of  the  stomach  may  be  confounded 
with  neurasthenia  gastrica.  Indeed,  it  maybe  a  complication 
of  most  of  the  chronic  diseases  of  the  stomach  which  occur 
in    nervous,    weak,    and    anemic    people.       Practically,     the 


NEURASTHENIA    GASTRICA.  343 

independent  form  of  neurasthenia  gastrica  may  have  to  be 
differentiated  from  chronic  asthenic  gastritis,  ulcer,  gastrop- 
tosis,  atypical  forms  of  cancer,  and  myasthenia  gastrica. 

If  the  clinical  expression  of  chronic  asthenic  gastritis  and 
neurasthenia  gastrica  be  carefully  studied,  it  will  be  seen  that 
the  two  diseases  resemble  each  other  only  when  the  symp- 
toms are  shorn  of  all  distinctive  features.  The  symptoms  of 
this  form  of  gastritis  are  digestive,  in  relation  with  the  solidity 
of  the  food  and  proportionate  to  its  physiological  action,  and 
the  cerebral,  circulatory,  and  distant  sensory  signs  (including 
the  tender  points)  of  neurasthenia  gastrica  are  absent.  A 
proper  diet,  strictly  followed,  in  gastritis  relieves  the  symp- 
toms, but  the  same  diet  is  of  little  value  in  neurasthenia  gas- 
trica. The  anatomical  signs  of  chronic  asthenic  gastritis 
are  of  absolute  differential  value — large  quantities  of  mucus 
in  the  test-meal  contents,  and  of  gastric  epithelium  and  of 
leukocytes  in  the  early  morning  washings  of  the  stomach, 
and  the  diminution  of  the  ferments.  Normal  secretion  and 
the  normal  digestive  transformation  of  the  food,  common  in 
neurasthenia,  exclude  gastritis;  and  rapid  but  slight  secretory 
variations,  not  due  to  local  irritation  of  the  mucous  mem- 
brane, are  in  favor  of  the  dynamic  affection.  Both  clinical 
forms  of  chronic  gastritis,  after  healing,  may  leave  the  nerves 
which  supply  the  stomach  abnormally  irritable. 

Ulcer  of  the  stomach  not  accompanied  by  severe  pain, 
hemorrhage,  or  vomiting  may  be  confounded  with  neuras- 
thenia gastrica.  The  differentiation  is  not  always  possible. 
The  discomfort  is  alike  digestive  in  both,  but  it  is  not  so  ex- 
clusively and  invariably  excited  by  taking  food  in  neuras- 
thenia. The  nerve-supply  is  in  both  alike  oversensitive,  but 
the  circumscribed  tender  points  of  ulcer  are  epigastric  and 
dorsal  ;  the  tender  neurasthenic  points  are  present  also  in 
other  parts  of  the  body.  Digestive  superacidity  is  the  rule 
in  ulcer  ;  it  is,  however,  rare,  and  is  not  persistently  present 
in  neurasthenia  gastrica.  In  the  one,  secretion  is  normal  or 
nearly  normal  ;  in  the  other,  secretion  is  normal  or  increased. 
In  the  one,  the  motor  function  is  normal  or  the  stomach 
splashes  during  digestion ;  in  the  other,  it  is  normal,  or 
signs  of  obstructive  retention  may  be  present.  There 
may  be  symptoms  of  general  neurasthenia,  or  the  discom- 
fort may  be  more  closely  related  to  the  state  of  the  mind 
and  of  the  spirits,  and  these  relations  would  be  in  favor  of 
the  dynamic  nature  of  the  trouble.  Each  individual  case 
may  present  symptoms  found  chiefly  or  exclusively  in  the 
one  or  the  other  disease  ;  but  the  differentiation,  even  in  the 


344  DISEASES  OF  l^HE  STOMACH. 

presence  of  the  somewhat  distinctive  features  of  the  coninion 
symptoms  and  signs,  is  a  mere  balancing  of  probabiHties. 
Tlie  diagnosis  should  often  be  left  to  the  subsequent  evo- 
lution of  the  case  or  be  inferred  from  the  results  of  appro- 
priate treatment.  The  continuance  of  the  discomfort  and 
digestive  unrest,  in  spite  of  rest  in  bed  and  a  strict  milk  diet 
combined  with  alkalies,  is  strongly  in  favor  of  neurasthenia. 

E.xceptionally,  atypical  or  latent  forms  of  carcinoma  may 
present,  particularly  in  the  early  period,  a  symptom-group 
somewhat  like  that  of  neurasthenia  gastrica,  which  may  also 
be  accompanied  by  emaciation  ;  but  after  thorough  study 
of  the  case,  its  etiology,  evolution,  symptoms,  and  signs, 
doubt  is  rarely  permissible. 

Gastroptosis  and  neurasthenia  gastrica  may  be  readily 
confounded.  The  displacement  of  the  stomach  is  easily 
detected  on  examination.  The  causal  relation  or  indepen- 
dence of  the  two  diseases  can  only  be  made  out  with  proba- 
bility from  the  history  and  from  the  results  of  appropriate 
treatment.  It  matters  little,  for  when  both  are  present  both 
must  be  treated. 

Neurasthenia  may  also  be  mistaken  for  myasthenia  gastrica 
— both  infrequently  being  expressed  chiefly  by  slight  diges- 
tive discomfort  and  by  flatulenc\%  The  absence  of  stagnation 
or  retention  often  decides  at  once  in  favor  of  neurasthenia 
gastrica.  In  neurasthenia  gastrica  the  motor  function  may 
also  be  insufficient,  but  this  is  seldom  true  except  in  the 
severe  cases  with  emaciation  and  loss  of  strength  ;  and 
the  state  of  nutrition  and  of  the  mind  and  spirits,  and  the 
nervous  disorders  are  out  of  all  proportion  to  the  slight 
motor  insufficiency.  In  neurasthenia  liquids  are  tolerated 
and  evacuated  more  readily  than  in  myasthenia,  as  is  made 
clear  by  the  water-test.  Myasthenia  is  also  constant,  is 
greatly  influenced  by  the  quantity  of  the  food,  and  is  with- 
out tender  points  and  cerebrasthenia  and  circulatory  disturb- 
ances. The  two  affections  may  coexist,  and  only  a  knowledge 
of  their  order  of  development  can  suggest  the  causal  rela- 
tions of  the  one  to  the  other.  The  typical  cases  of  the  two 
affections  bear  little  resemblance  if  the  distinctive  features 
are  closely  studied. 

Prognosis. — Neurasthenia  gastrica  is  not  a  fatal  disease, 
but  it  often  proves  very  obstinate  to  treatment.  It  creates  a 
predisposition  to  the  development  of  congestion  and  inflamma- 
tion of  other  organs  through  the  vasomotor  and  circulatory 
disorders  e.xcited  by  it.  The  resistance  of  the  organism  to 
invasion  is  notably  weak. 


NEURASTHENIA    GASTRICA.  345 

The  benefits  of  treatment  are  conditioned  by  the  ability 
of  the  physician  completely  to  control  the  patient.  The 
common  sense,  desires,  and  will  must  be  united  in  one  effort 
to  get  well  under  the  strict  employment  of  the  proper  reme- 
dies. The  life — mental,  moral,  physical,  and  social — must 
be  controlled  and  regulated  in  the  severe  cases.  The  mild 
cases  may  recover  under  gentler  restrictions.  When  properly 
rested  and  fed,  and  firmly  led  into  optimism  by  the  physician, 
the  prognosis  is  good  and  the  duration  of  the  treatment  is 
shortened. 

Treatment. — The  treatment  of  neurasthenia  gastrica  should 
be  methodical  and  consistent.  Failure  is  often  the  result 
of  a  lack  of  unity  and  plan  in  the  employment  of  remedies. 
Nothing  is  more  important  than  the  combination  of  all  means 
which  make  for  the  repose  and  strength  and  conservation  of 
the  nervous  system.  Rest  alone  will  do  little  good.  Isola- 
tion alone  will  not  accomplish  much.  Diet  alone  is  often  of 
little  benefit.  Drugs  unaided  often-fail  even  to  relieve  symp- 
toms. Repose  of  mind  and  body  and  good  digestive  hj-giene 
are  of  little  value  when  combined  with  excitant  remedies. 
All  sources  of  excessive  irritation  should  be  cut  off,  and  all 
excessive  waste  avoided.  The  irritable  weakness  can  be  best 
relieved  by  suitable  repose,  by  the  conservation  of  energy, 
and  by  enough  exercise  and  functional  activity  to  develop 
tone  and  strength  in  the  individual  case.  Aimless  manage- 
ment without  method  either  does  harm  or  no  good. 

In  order  to  control  the  patient  in  every  particular  it  is 
necessary  to  possess  his  confidence  and  the  sympathetic  aid 
of  those  in  communication  with  him.  Under  no  other  cir- 
cumstances can  his  mind  and  spirits  be  controlled  and  utilized 
by  suggestive  therapy  to  influence  the  abdominal  sympa- 
thetic. This  mental  and  moral  guidance  is  all  the  more 
imperative  when  the  affection  is  cerebrogastric. 

The  nutrition  must  be  good  and  the  sleep  sufficient  and 
restful  before  any  improvement  can  be  expected.  To  this 
end  hygienic  remedies  and  diet  are  most  conducive. 

A  warm  and  sunny  climate,  proper  clothing,  change  of 
scene,  rest  from  business  and  other  cares,  electricity,  massage, 
active  exercise,  and  hydrotherapy  have  the  same  value  as  in 
the  treatment  of  general  neurasthenia.  These  physical  and 
mechanical  remedies  are  most  beneficial  when  mild  and 
soothing.  The  amount  of  excitation  to  be  produced  varies 
with  each  individual  case,  but  the  after-effect  should  never 
be  exhaustion  or  restlessness.  The  right  method  has  been 
found  when  it  increases   the  desire  for  food,  secures   sound 


346  DISEASES  OF  THE  STOMACH. 

sleep,  and  relieves  the  unrest.  The  contrary  effect  is  a  sign 
of  too  niuch  or  too  prolon^^ed  excitation. 

The  quantity  of  the  food  is  regulated  by  the  state  of  nutri- 
tion, but  the  diet  is  selected  by  its  physiological  action  on 
the  sensibility  of  the  stomach,  provided  there  be  no  associated 
disease  or  complication.  Rationally,  a  diet  that  has  but  little 
action  on  secretion  would  be  exoected  to  be  most  suitable, 
and  this  is  usually  the  case.  Milk  is,  consequently,  in  neu- 
rasthenia gastrica,  an  appropriate  food,  and  the  finely-divided 
and  thoroughly  cooked  cereals  may  be  combined  with  it. 
Fats,  of  which  the  best  is  unsalted  butter,  are  commonly  well 
borne,  and  fulfil  an  essential  purpose  in  nutrition.  Fish  and 
stewed  white  young  meats  agree  better  than  the  roasted  and 
broiled  red  meats.  Nothing  is  more  disastrous  than  a  dry 
diet  composed  of  meats,  unless  it  be  a  mixture  of  acids, 
salads,  sweets,  pastry,  pies,  alcohdlic  drinks,  and  highly  sea- 
soned dishes.  Green  vegetables  can  be  sparingly  used,  while 
ripe  and  not  very  sweet  nor  acid  but  soft  and  juicy  fruits  can 
often  be  prescribed  as  nutriment  and  as  remedies  against  the 
constipation.  The  diet  should  always  be  sufficient  to  sup- 
port or  improve  nutrition  in  the  particular  case,  and  other 
articles  should  be  added  to  it  as  more  and  more  excitation 
of  the  mucous  membrane  is  likely  to  be  beneficial.  The 
supreme  clinical  control  of  the  rationally  selected  diet  in 
neurasthenia  gastrica  is  furnished  by  the  subjective  sensations 
of  the  patient.  If  the  discomfort  is  relieved,  the  diet  is  right 
in  its  action;  if  the  unrest  be  increased,  the  diet  is  wrong, 
unless  some  other  error  is  being  committed.  Often  the 
proper  diet  is  more  exciting  than  would  be  rational!}'  expected. 

A  valuable  local  remedy  in  many  cases  is  the  intragastric 
douche,  employed  before  breakfast  or  at  bedtime,  particu- 
larly in  the  severe  and  in  the  cerebrog^stric  cases.  The  tem- 
perature of  the  water  should  be  regulated  according  to  the 
irritability  of  the  particular  case.  In  the  obstinate  cases,  with 
gre  it  digestive  discomfort,  the  stomach  may  be  first  douched 
with  water,  and  then  one-half  to  one  pint  of  a  i  :  2000  solution 
of  nitrate  of  silver  may  be  allowed  to  flow  into  the  empty 
stomach  through  the  douche-tube,  and  then  be  immediately 
withdrawn.  After  its  removal  the  stomach  is  again  irrigated 
with  i)lain  water.  The  nitrate  of  silver  douche  may  be  used 
once,  or  at  most  twice,  a  week. 

A  large  quantity  of  tonics  and  nervines  is  usually  given, 
sometimes  with  benefit  but  often  with  injury.  No  .salines,  no 
alkalies,  and  no  antiseptics  should  be  employed.  Iron,  in  its 
least   irritant    and    least    constipating    forms,  or   well-diluted 


MYASTHENIA   GASTRICA.  347 

arsenic  may  be  required  by  anemia.  The  infusion  of  condu- 
ranG;;o  seems  to  be  the  most  beneficial  bitter.  Small  doses 
of  the  bromids  (sodium  or  strontium)  often  undoubtedly  do 
good  for  a  short  time.  It  may  be  advisable  or  necessary  to 
use  soporifics.  The  constipation  is  best  treated  by  massage, 
oil  or  glycerin  injections,  electricity,  and  a  proper  diet.  The 
common  practice  of  frequently  irritating  the  stomach  with  so- 
called  reconstituent  drugs  can  not  be  too  strongly  condemned 
in  the  management  of  neurasthenia  gastrica. 

The  etiological  treatment  should  receive  careful  considera- 
tion. Enteritis,  intestinal  irritation  (tape-  or  other  worms), 
enteroptosis,  movable  kidney,  anemia,  disease  of  the  genital 
or  urinary  organs,  associated  gastric  troubles  (particularly 
gastroptosis),  and  whatever  has  prepared  the  soil  or  occa- 
sioned the  genesis  and  aided  the  evolution  of  the  affection, 
should  have  proper  attention,  in  keeping  with  a  fundamental 
principle  of  therapeutics. 


CHAPTER  V. 
MYASTHENIA  GASTRICA. 

Myasthenia  {jm<z,  muscle,  and  aaOsvsia,  weakness)  gastrica  is 
a  dynamic  affection  of  the  stomach,  characterized  by  dim- 
inution of  the  elasticity  and  strength  of  its  muscular  layer. 
The  stomach  does  not  empty  itself  within  the  normal  period, 
and  is  distended  more  easily  by  its  contents,  on  which  it  re- 
tracts with  less  than  its  normal  force.  Myasthenia  is  prim- 
arily and  essentially  an  independent  dynamic  affection  of  the 
stomach.  Pathologically,  many  claim  for  it  a  place  among 
the  nervous  affections  of  the  organ.  The  nervous  system 
may  play  a  part  in  its  genesis,  but  essentially  it  is  a  muscular 
affection.  The  muscle  is  everything,  and  is  insufficient  be- 
cause it  is  weak  or  degenerated. 

In  its  course  the  disease  may  pass  through  all  degrees  of 
motor  insufficiency,  varying  from  a  slight  deviation  from 
health  to  absolute  gastric  retention.  Clinically,  the  evolu- 
tion of  the  disease  may  be  divided  into  two  periods  :  the  one 
being  characterized  by  stagnation,  the  stomach  slowly  empty- 
ing itself  completely  between  meals  or  during  the  night  only  ; 
the  other  by  retention,  the  stomach  always  containing  food. 


34^  DISEASES  OF  THE  STOMACH. 

Etiology. — Myasthenia  is  the  most  frequent  dynamic  affec- 
tion of  the  stomach,  occurring  regardless  of  sex  and  at  all 
ages. 

The  predisposition  to  the  disease  may  be  hereditary,  per- 
sons being  born  with  weak  muscles  as  with  weak  nerves  or 
mucous  membranes.  Whole  families  may  have  it,  yet  it 
may  be  impossible  to  attribute  it  to  a  common  dietetic  error 
or  mode  of  life  or  to  other  common  pathogenic  influences. 
The  causes  of  myasthenia  are  exceedingly  numerous,  and  it 
is  very  difficult  to  determine  precisely  its  relation  to  heredity. 
The  very  frequent  occurrence  of  the  disease  in  families  pos- 
sessing an  undeniable  hereditary  taint — the  neurotic,  the 
arthritic,  and  in  families  afflicted  with  the  series  of  diseases 
characterized  by  slow  and  imperfect  catabolism — would  seem 
to  indicate  that  a  myasthenic  predisposition  may  be  inherited. 

The  disease  is  more  frequently  acquired,  and  it  is  rare  that 
a  myasthenic  person  can  pose  with  much  show  of  reason  as 
a  victim  of  heredity.  A  mild,  and  often  a  temporary,  form 
is  produced  by  mental  fatigue  and  by  depressing  moral 
causes.  The  shock  of  fear,  of  accidents,  or  of  grave  mis- 
fortune may  be  the  cause  of  the  relaxation  of  the  voluntary 
and  involuntary  muscular  systems;  and  myasthenia  gastrica 
can  be  thus  produced,  particularly  if  the  shock  comes  during 
gastric  digestion.  Prolonged  mental  and  physical  fatigue 
can  have  the  same  result.  But  myasthenia  gastrica  pro- 
duced in  this  acute  manner  is  most  frequently  mild  in  degree, 
and  recovery  may  be  rapid;  but  under  conditions  favorable 
to  its  further  development  the  disease  may  become  progres- 
sive and  serious. 

Myasthenia  gastrica  is  an  almost  constant  sequel  of  severe 
acute  diseases.  During  convalescence,  when  the  appetite 
represents  more  closely  the  needs  of  nutrition  than  the  func- 
tional power  of  the  stomach,  the  weak  organ  is  often  over- 
loaded, and  the  gastric  myasthenia  frequently  persists  in 
spite  of  the  improvement  in  the  general  strength  and  in 
nutrition.  Typhoid  fever,  influenza,  and  diphtheria  deserve 
particular  mention  in  this  connection,  though  many  other 
adynamic  diseases  leave   the  stomach  in  the  same   condition. 

Many  chronic  diseases  are  predisposing  or  efficient  causes. 
It  is  one  of  the  gastric  affections  of  the  initial  stage  of  pul- 
monary tuberculosis.  Diseases  of  the  heart,  of  the  lungs,  and 
of  the  liver,  accompanied  by  congestion  of  the  portal  circula- 
tion, often  cause  myasthenia  gastro-intestinalis.  It  is  very 
common  in  gout,  in  uricemia,  in  biliary  lithiasis,  in  diabetes, 
in  severe  anemias,  and  after  severe   hemorrhages.     All  dis- 


MYASTHENIA   GASTRICA.  349 

eases  accompanied  by  malnutrition  or  subnutrition  are  predis- 
posing causes. 

Myasthenia  may  be  a  complication  of  many  of  the  diseases 
of  the  stomach,  and  its  development  renders  the  situation 
much  more  serious.  Among  the  many  causative  gastric  dis- 
eases maybe  mentioned  chronic  gastritis  (chiefly  hypersthenic 
form),  displacements  of  the  stomach,  and  carcinoma. 

The  disease  may  also  be  caused  by  dietetic  errors,  partic- 
ularly intemperance  in  eating  and  drinking,  the  overtaxed 
gastric  muscle  becoming  fatigued,  insufficient,  and  less  retrac- 
tile. Very  large  and  bulky  meals,  large  quantities  of  effer- 
vescent drinks,  large  drafts  of  water  in  summer,  rapid 
and  excessive  beer-drinking,  and  the  drinking  of  large  quan- 
tities of  hot  water  or  of  mineral  waters  are  common  errors, 
which,  repeated  often,  may  directly  produce  myasthenia. 
Myasthenia,  according  to  its  severity,  may  be  accompanied 
by  stagnation  or  by  retention  of  the  gastric  contents. 

I.  Myasthenia  with  Stagnation. 

Clinical  Description. — Myasthenia  with  stagnation  is  very 
variable  in  its  severity.  The  degree  of  stagnation  measures 
precisely  the  degree  of  myasthenia.  The  period  of  gastric 
digestion  (which  naturally  varies  with  the  quality  and  the 
quantity  of  the  meal)  may  be  but  slightly  prolonged,  or  the 
stomach  may  get  a  short  rest  only  in  the  early  morning. 
Two  forms  should  be  clearly  separated,  the  one  being  mild 
and  the  other  severe.  In  the  mild  form  of  stagnation 
myasthenia  the  stomach  is  empty  later  than  it  normally 
should  be,  but  the  evacuation  of  the  contents  of  the  stomach 
is  complete  between  meals.  In  the  severe  form  of  stagna- 
tion myasthenia  the  stomach  is  not  empty  before  the  mid- 
day nor  before  the  evening  meals,  but  is  empty  for  a  short 
period  before  breakfast.  The  inability  of  the  stomach  to 
evacuate  its  contents  during  the  twenty-four  hours  character- 
izes the  retention  form  of  myasthenia,  in  which  form  the 
stomach  always  contains  food  under  the  circumstances  im- 
posed by  ordinary  dietetic  customs.  Both  mild  and  severe 
stagnation  myasthenia  may  be  latent,  the  disease  being  ex- 
pressed only  by  its  physical  signs.  The  stomach  empties 
itself  later  than  in  health,  remains  flaccid,  as  evidenced  by 
splashing,  throughout  the  digestive  period,  and  distends 
excessively  under  the  weight  of  a  moderate  quantity  of  con- 
tents. The  balance  of  nutrition  is  maintained,  but  it  is  im- 
possible   to    increase  the   weight   of  the  body.     The  patient 


350  DISEASES  OF  THE  STOMACH. 

does  not  complain,  but  is  exposed  to  digestive  disorder  when 
a  very  large  meal  is  eaten,  or  when  the  usual  quantity  of 
food  is  taken  while  the  body  and  mind  are  fatigued. 

This  latent  period  may  last  a  number  of  weeks,  or  even 
years,  before  the  clinical  period  develops.  This  is  the  com- 
mon mode  of  development  when  the  predisposing  cause  is 
heredity,  or  when  the  myasthenia  follows  acute  or  chronic 
disease,  or  when  it  is  due  to  faulty  digestive  hygiene.  The 
clinical  period  may  appear  suddenly,  after  shock  or  depress- 
ing emotions,  or  physical  or  mental  fatigue,  or  after  a  dietttic 
error  or  excess. 

The  symptoms  of  the  clinical  period  are  digestive,  the 
short  intervals  when  the  stomach  is  empty  being  passed 
without  discomfort.  Soon  after  food  is  taken  the  stomach 
feels  full  and  heavy,  and  the  air  swallowed  and  the  carbon 
dioxid  set  free  from  the  carbonates  of  the  food  and  the 
saliva  by  the  secreted  hydrochloric  acid  distend  the  stomach, 
often  to  such  a  degree  that  the  clothing  must  be  loosened. 
The  gas  is  removed  by  frequent  belching,  bringing  with  it 
often  a  little  fluid  into  the  esophagus  or  mouth;  and  this  is 
one  of  the  most  constant  symptoms  of  the  trouble.  The 
distention  of  the  stomach  is  thus  diminished,  but  the  sensa- 
tions of  weight  and  fullness  only  gradually  disappear  as  the 
stomach  lazily  empties  its  contents  into  the  duodenum.  If 
the  meal  be  large  the  gastric  distress  may  become  greater 
and  greater,  until  the  stomach  empties  itself  by  copious  vom- 
iting, after  which  there  is  no  more  trouble  until  another  meal 
is  eaten.  The  duration  and  the  intensity  of  the  symptoms 
are  dependent  on  the  quantity  of  food  eaten,  and  in  the  mild 
cases  the  symptoms  may  appear  only  after  the  chief  meal. 
In  the  severe  form  the  muscular  elasticity  is  still  further 
diminished,  and  the  discomfort  may  occur  after  each  meal, 
and  may,  indeed,  sometimes  be  produced  by  drinking  a  glass 
of  water.  The  appetite,  which  is  usually  good  before  meals, 
may  be  quickly  satisfied.  A  symptom  of  differential  value 
is  the  relation  of  the  gastric  symptoms  to  the  quality  of  the 
food,  the  symptoms  being  excited  by  both  fluid  and  solid 
food,  fluids  often  producing  as  much  distress  as  an  ordinary 
mi.xed  meal.  This  symptom  is  exceedingly  rare  in  any 
other  uncomplicated  disease  of  the  stomach.  Such  is  the 
simple  form  of  stagnation  myasthenia,  characterized  by  di- 
gestive symptoms  in  close  relation  with  the  quantity  and 
the  fluidity  of  the  food;  by  belching  and  regurgitation  ;  by  a 
mere  maintenance  of  the  balance  of  nutrition;  by  physical 
and  mental  exhaustion  after  moderate  exercise  or  effort ;  and 
by  the  physical  and  functional  signs  of  myasthenia. 


MYASTHENIA   GASTKICA.  35  I 

But  the  disease  does  not  always  remain  so  mild  and  sim- 
ple. The  stagnation  is  a  favorable  condition  for  fermentation, 
and  the  regurgitations  may  have  the  odor  and  taste  of  organic 
acids ;  but  we  would  particularly  emphasize  the  fact  that  fer- 
mentation is  rare  even  in  the  severe  form  of  stagnation  myas- 
thenia. In  some  cases,  however,  it  does  occur  irregularly  and 
intermittently.  To  the  symptoms  already  enumerated  may 
be  added  gastralgia,  pain,  often  nausea  and  vomiting,  head- 
ache, sometimes  insomnia,  and  mental,  moral,  and  physical 
depression,  vertigo,  peripheral  and  central  disorders  of  the 
circulation,  erythema,  urticaria,  slow  and  labored  action  of  the 
heart,  with  a  reduplication  of  the  second  sound. 

In  consequence  of  the  prolonged  sojourn  of  the  contents  in 
the  stomach  (and,  rarely,  of  fermentation),  the  gastric  glands 
may  become  irritable,  and  secretion  may  continue  for  a  short 
time  after  the  evacuation  of  the  chyme  into  the  intestines,  or 
there  may  be  simple  hyperchlorhydria.  This  condition  is  ex- 
pressed by  gastric  pain,  hydrochloric  heartburn  and  pyrosis, 
thirst,  and  sometimes  a  sharp  appeiite  and  headache.  In 
still  other  cases  the  secretion  may  become  continuous  during 
the  day,  and  the  uninterrupted  irritation  may  produce  the 
hypersthenic  form  of  chronic  gastritis,  which  is  a  most  seri- 
ous sequel  of  myasthenia. 

In  stagnation  myasthenia  the  bowels  are  usually  consti- 
pated, but  when  myasthenia  intestinalis  (a  common  complica- 
tion or  association)  becomes  well  marked,  the  whole  clinical 
aspect  of  the  case  is  changed.  The  nervous  and  constitu- 
tional symptoms  (attributed  wrongly  by  some  authors  to 
gastric  auto-intoxication)  appear;  and  there  is  constipation, 
insomnia,  headache,  neurasthenia,  oligocythemia,  chlorosis, 
disorders  of  the  circulation,  and  hepatic  congestion.  The 
intestinal  myasthenia  may  become  the  most  prominent 
trouble  and  be  manifested  by  periodical  colalgia,  localized 
colitis,  spasm  alternating  with  localized  dilatations,  intestinal 
supersecretion,  and  the  discharge  of  muco-albuminous  mem- 
branes infected  with  bacteria.  When  the  intestines  become 
involved  malnutrition  begins,  and  may  lead  to  extreme 
emaciation  and  intestinal  cachexia. 

The  preservation  of  the  strength,  the  weight,  and  the  ap- 
pearance of  good  health  is  a  marked  characteristic  of  simple 
myasthenia  gastrica  with  stagnation.  The  disease  itself  has 
no  influence  on  general  nutrition,  the  food  being  eventually 
as  well  utilized  as  in  health.  If  emaciation  occurs,  it  is 
due  to  an  insufficient  or  an  improper  diet  or  to  a  complica- 
tion.    The  symptoms  being  digestive,  and  increasing  in  pio- 


352  DISEASES  OF  THE  STOMACH. 

portion  to  the  quantity  of  food,  and  the  appetite,  even  in  the 
mild  cases,  being  often  satisfied  with  a  \&\v  niouthfuls,  the 
patient  is  very  Ukely  to  eat  less  than  is  necessary  to  supply 
the  nutritive  demands  of  the  body.  It  is  not  rare,  also,  for  a 
myasthenic  to  adopt  an  exclusive  monotonous  diet,  as  the 
consequent  diminution  of  the  quantity  of  food  gives  relief. 
Whenever,  in  myasthenia  with  stagnation,  emaciation  exists, 
starvation,  or  a  gastric  complication,  or  an  associated  disease 
of  another  organ  will  be  found.  The  urine,  both  in  its  quan- 
tity and  qualit}',  is  unchanged,  except  when  there  is  an  asso- 
ciated secretory  disorder  or  an  insufficient  quantity  of  fluids 
is  taken. 

The  objective  signs  are  more  characteristic  than  the  sub- 
jective symptoms.  These  signs  are  conditioned  by  the  state 
and  the  degree  of  efficiency  of  the  muscular  layer,  which 
distends  easily  and  retracts  imperfectly  on  the  contents.  The 
stomach  empties  itself  slowly  but  completely,  and  even  in 
the  severe  stagnation  form  no  food  is  found  in  the  stomach 
in  the  morning  before  breakfast. 

A  great  deal  of  time  may  be  spent,  and  partly  wasted,  in 
the  endeavor  to  determine  with  exactness  the  size  of  the 
stomach  by  percussion,  by  the  limits  of  the  splashing  sounds, 
by  distention  with  gas  or  air,  and  by  electric  illumination. 
The  size  of  the  stomach  bears  no  relation  to  its  motor  power, 
but  an  extension  of  the  average  limits  of  the  stomach  would 
suggest  the  presence  of  a  ph)'siologically  large  stomach  or 
of  one  of  a  group  of  the  diseases  of  this  organ,  of  which 
group  of  diseases  the  stagnation  form  of  myasthenia  is  a 
member. 

In  myasthenia  with  stagnation  inspection  is  negative — no 
visible  peristalsis,  no  particular  changes  of  the  form  of  the 
abdomen,  but  at  times  the  distended  stomach  may  produce  a 
visible  prominence. 

On  palpation  the  stomach  will  never  be  found  firmly  con- 
tracted and  resistant,  but  flabby  and  flat,  unless  distended 
with  a  very  large  quantity  of  contents,  when  its  form,  size, 
and  position  may  be  sometimes  determined. 

Percussion  gives  some  signs  of  diagnostic  value.  The 
pyloric  portion  may  extend  beyond  the  normal  limits  to  the 
right;  but  it  may  be  impossible  to  demonstrate  this  if  the 
hepatic  flexure  of  the  colon  is  filled  with  gas.  The  lower 
border  may  often,  but  by  no  means  always  or  necessarily,  be 
below  the  line  joining  the  umbilicus  and  the  tip  of  the  car- 
tilage of  the  ninth  rib.  During  digestion,  if  the  time  be 
taken  to  search   for  the  sign,  the  percussion  note   over  the 


MYASTHENIA   GASTRIC  A.  353 

uncovered  triangle  changes  with  the  peristaltic  movements, 
and  it  changes  also  over  the  area  of  the  stomach  accessible 
to  percussion  when  the  position  of  the  patient  is  altered. 

Myasthenia,  however,  can  not  be  detected  by  inspection, 
palpation,  and  percussion,  nor  by  inflation  and  electric  illumi- 
nation, for  the  object  is  not  the  determination  of  the  size, 
form,  and  position  of  the  stomach,  but  the  estimation  of  the 
tone  and  strength  of  its  muscular  layer.  The  methods  of 
Penzoldt  and  Dehio  are  of  more  value  if  used  with  the 
proper  precautions.  The  liver  and  the  stomach  are  first 
mapped  out  by  palpation  and  percussion,  while  the  patient  is 
recumbent  and  fasting.  The  position  of  the  left  lobe  of  the 
liver  and  of  the  greater  curvature  of  the  stomach  should  be 
next  determined  as  accurately  as  possible  while  the  patient 
stands  erect.  It  is  necessary  to  do  this  while  the  patient  is 
standing  in  order  to  make  allowance  for  the  descent  of  the 
abdominal  viscera  produced  by  the  erect  position.  This 
descent  varies  from  a  fraction  to  two  or  three  inches,  and  the 
greater  curvature  would  be  displaced  downward,  not  by  re- 
laxation of  its  walls,  but  by  total  descent.  After  the  new 
boundaries  have  been  marked,  half-glasses  of  water  are  ad- 
ministered after  short  intervals,  during  which  the  change  in 
the  location  of  the  greater  curvature  is  determined  by  per- 
cussion, the  patient  being  erect.  The  distance  of  the  dislo- 
cation is  directly  proportionate  to  the  myasthenia,  and  the 
quantity  of  water  required  to  produce  the  greatest  descent 
is  inversely  proportionate  to  the  myasthenia.  Generally,  a 
liter  of  water  does  not  cause  the  greater  curvature  of  the 
normal  stomach  to  descend  below  the  umbilicus.  Many 
difficulties  exist  in  the  practice  of  these  methods,  and  we 
rarely  employ  them. 

The  most  valuable  physical  sign  of  myasthenia  with  stag- 
nation is  percussion  splashing  located  in  the  stomach,  and 
this  alone  is  sufficient  to  establish  the  diagnosis  of  motor 
insufficiency  when  the  proper  precautions  are  taken.  These 
splashing  sounds  are  usually  absent  in  the  healthy,  vigorous 
stomach  at  all  moments  of  the  digestive  period  except  toward 
the  end  of  the  digestion  of  a  very  large  meal.  The  myas- 
thenic stomach  splashes  throughout  the  digestive  period,  and 
also  later  than  the  moment  when  the  normal  stomach  should 
be  empty,  the  evacuation  of  the  stomach  being  delayed.  Two 
glasses  of  water  given  on  an  empty  healthy  stomach  are  passed 
into  the  duodenum  without  its  being  possible  (or,  rarely,  for 
a  period  of  a  few  minutes)  to  elicit  gastric  splashing.  The 
myasthenic  stomach,  under  the  same  circumstances,  splashes 
23 


354  DISEASES  OF  THE  STOMACH. 

for  two  hours,  or  even  longer.  In  the  mild  form,  and  in  some 
of  the  cases  of  the  severe  form  of  stagnation  myasthenia,  an 
examination  may  give  intermittent  splashing  (during  a  meal  or 
after  the  administration  of  water).  The  stomach  has  enough 
tone  to  retract  during  peristalsis,  but  it  relaxes  completely 
during  the  periods  of  peristaltic  inactivity.  If  a  glass  of 
water  be  given  on  an  empty  stomach,  the  gliding  method  of 
palpation  shows  the  nearly  empty  stomach  to  be  flabby,  non- 
retracted,  e.xtending  over  a  large  area  and  the  greater  cur- 
vature, caught  between  the  compressing  fingers  and  the  pos- 
terior abdominal  wall,  offers  little  resistance  to  fixation  during 
expiration. 

While  the  splashing  sounds  give  valuable  information  con- 
cerning the  tone  and  power  of  the  muscular  wall,  the  stomach- 
tube  may  be  used  to  determine  the  motor  insufficiency  with 
great  exactness.  Seven  hours  after  a  Leube-Riegel  meal 
the  stomach  should  contain  no  food.  After  the  test-break- 
fast the  quantity  of  contents,  determined  exactly  by  the 
methods  of  Mathieu  or  Strauss,  is  greater  than  normal,  the 
increase  above  the  150  c.c.  revealing  the  motor  insufficiency. 
The  increased  quantity  of  contents  may,  however,  be  due  to 
supersecretion  or  to  swallowed  saliva.  The  emulsion  meal 
of  Mathieu,  or  our  absorption  test-meal,  would  eliminate  this 
possible  source  of  error.  The  stomach  before  breakfast  or 
the  morning  after  the  administration  of  Boas'  evening  test- 
meal,  contains  no  food  in  the  stagnation  form. 

We  commonly  adopt  the  following  method  of  procedure, 
the  existence  of  motor  insufficiency  having  been  revealed  by 
the  splashing  sounds  or  by  the  excessive  quantity  of  contents 
one  hour  after  the  Ewald-Boas  test-breakfast.  If  the  stom- 
ach splashes  in  the  early  morning  before  any  food  or  fluid 
has  been  taken,  a  Boas  evening  meal  is  ordered,  and  the 
stomach  is  examined  the  ne.xt  morning  for  retained  contents. 
If  the  stomach  contains  no  food,  retention  does  not  exist.  A 
breakfast  consisting  of  two  soft-boiled  eggs,  one  roll,  a  little 
butter,  and  a  cup  of  weak  tea  or  coffee  (milk  and  sugar 
allowed)  is  ordered  at  8  o'clock,  and  at  i  o'clock  the  stomach 
is  examined.  If  it  be  found  empty  the  severe  form  of  stag- 
nation does  not  e.xist.  If  it  contains  remnants  of  the  breakfast 
there  is  severe  stagnation,  which  may  be  due  to  myasthenia 
or  to  obstruction.  Two  glasses  of  water  are  given  on  the  fol- 
lowing morning  before  breakfast.  One  and  one-half  hours 
later  the  stomach  is  examined.  If  the  stomach  is  empty  there 
is  no  myasthenia,  but  there  is  obstructive  stagnation.  If  the 
stomach  is  not  empty,  the  myasthenia  is  proportionate  to  the 


MYASTHENIA   GASTRIC  A.  355 

quantity  of  water  which  is  found  in  the  stomach.  The  quantity 
of  water  may  be  exactly  determined  by  introducing  lOO  c.c.  of 
a  one  per  cent,  solution  of  dextrose  or  sugar,  mixing  it  with 
the  stomach-contents,  and  subtracting  lOO  from  the  result 
obtained  by  dividing  lOO  by  the  estimated  percentage  of  sugar 
in  the  expressed  dilution.  If  the  stomach  secretes  excessively, 
the  analysis  of  the  liquid  withdrawn  will  reveal  it.  This  pro- 
cedure constitutes  the  important  water-test,  which  not  only 
reveals  the  myasthenia  (a  "  dyspepsia  of  liquids  "),  but  dis- 
tinguishes myasthenic  from  obstructive  stagnation. 

In  stagnation  myasthenia  the  stomach  is  empty  in  the  early 
morning  before  breakfast,  but  digestion  and  secretion  are 
prolonged.  The  stomach  works  longer  than  it  should  and 
secretes  longer  than  it  should;  but  myasthenia  does  not  pre- 
sent a  constant  chemical  type,  for  secretion  displays  irregular 
variations.  The  three  stages  of  digestion — rise,  continuance, 
and  decline — may  be  simply  prolonged,  with  no  noteworthy 
quantitative  variations  of  the  total  hydrochloric  acid  from  the 
normal  type.  More  frequently  free  HCl  appears  abnormally 
early  and  the  combined  HCl  gradually  increases,  and  during 
the  latter  stage  of  digestion  is  abnormally  high,  for  the 
secreted  HCl  is  not  rapidly  utilized  and  the  digestive  pro- 
ducts accumulate.  The  period  of  decline  of  digestion  is 
prolonged  like  the  other  stages,  and  it  does  not  end  suddenly, 
as  often  happens  in  obstructive  stagnation.  The  lines  repre- 
senting the  evolution  of  the  free  HCl  and  of  the  combined 
HCl  may  be  irregular,  with  sudden  rises  and  falls,  for  the 
evacuation  of  the  contents  may  be  irregular  and  in  spurts; 
but  these  lines  may  also  be  irregular  in  obstructive  stagna- 
tion. In  stagnation  myasthenia  the  total  HCl  (H  -f-  C)  may 
be  less  than  normal,  the  combined  HCl  gradually  increasing 
as  digestion  proceeds.  If  the  HCl  secreted  is  greatly  and 
constantly  diminished,  the  co-existence  of  stagnation  should 
arouse  suspicion,  for  this  combination  of  functional  signs  is 
rare  in  myasthenia;  but  it  is  frequent  in  carcinoma,  in  chronic 
gastritis  with  infiltration  of  the  muscular  layer,  and  in  the 
complicated  cases  of  pyloric  obstruction.  In  adenasthenia 
gastrica  and  in  simple  chronic  asthenic  gastritis  the  stomach 
empties  itself  with  normal  or  abnormal  rapidity,  for  its  motor 
power  is  good  and  the  digestive  work  which  it  is  capable  of 
doing  is  quickly  finished.  To  detect  these  abnormalities  of 
the  evolution  of  secretion  it  is  necessary  to  remove  and  ana- 
lyze the  contents  of  the  stomach  thirty,  sixty,  and  one  hun- 
dred and  twenty  minutes  after  the  beginning  of  the  test- 
breakfast.     With  the  exception  of  these  evolution  disorders 


356  DISEASES  OF  THE   STOMACH. 

tliere  are  no  abnormal  secretory  signs  in  stagnation  myas- 
thenia. We  would  particularly  emphasize  the  almost  invari- 
able absence  of  abnormal  bacteriological  signs.  There  is  no 
excessive  germ  growth,  no  fermentation,  and  no  gas  forma- 
tion in  the  fermentation  tube  tests.  Very  rarely  there  are  a 
few  yeast  cells. 

The  evolution  of  nu'asthenia  with  stagnation  is  variable. 
Developing  as  the  sequel  of  an  acute  disease,  it  may  rapidly 
disappear  under  proper  treatment.  It  may  be  arrested  at 
any  stage,  whatever  be  the  cause.  When  a  hereditary  pre- 
disposition exists  it  may  last  from  childhood  to  old  age, 
but  be  controllable  by  proper  digesti\'e  hygiene.  However 
caused,  the  form  with  stagnation  may  rapidly  or  slowly  grow 
into  the  form  or  period  characterized  by  retention.  Its 
course  may  be  broken  by  latent  periods,  characterized  only 
by  physical  signs,  or  by  exacerbations  due  to  physical, 
mental,  or  nervous  exhaustion,  or  to  dietetic  excesses. 

Diagnosis. — The- diagnosis  of  myasthenia  gastrica  is  easy 
if  the  modern  methods  of  examination  be  emplo}'ed.  The 
restriction  of  the  symptoms  to  the  prolonged  digestive  period 
and  their  relation  witli  the  quantity  and  fluidity  of  the  food  ; 
the  delayed  evacuation  of  the  flabby,  easily  distensible,  and 
slightly  retractile  splashing  stomach  ;  the  absence  of  food  in 
the  fasting  morning  stomach  ;  the  absence  of  a  characteristic 
germ  growth  or  secretory  deviation  ;  the  mode  of  develop- 
ment and  the  usual  maintenance  of  nutrition — are  suflficiently 
characteristic. 

Differential  Diagnosis. — The  diseases  most  likely  to  be 
confounded  with  the  stagnation  form  of  myasthenia  gastrica 
are  neurasthenia  gastrica,  displacements  of  the  stomach, 
pyloric  obstruction,  cancer,  chronic  gastritis,  and  myas- 
thenic gastric  retention. 

In  both  neurasthenia  and  myasthenia  the  subjective  symp- 
toms are  digestive,  and  may  be  similar;  but  in  neurasthenia 
the  subjective  symptoms  are  not  proportionate  to  the  quan- 
tity of  the  food,  and  are  commonly  more  pronounced  with 
solids  than  with  fluids.  In  myasthenia  the  symptoms  are 
greatest  after  large  meals,  and  are  least  after  small  meals  of 
finely-divided  solid  food  with  little  fluid.  Gastric  excitants, 
particularly  condiments  and  irritant  drugs,  increase  greatly 
the  uneasiness  and  discomfort  of  neurasthenia,  and  are  com- 
paratively well  borne  in  the  mild  form  of  myasthenia.  In 
neurasthenia  the  abdominal  plexuses  are  sensitive,  and  pres- 
sure, particularly  during  the  period  of  functional  activity  of 
the  digestive  tube,  over  the  four  points  situated  a  little  below 


MYASTHENIA   GASTRICA.  357 

the  ensiform  process,  to  either  side  of  the  umbilicus,  and 
above  the  symphysis  pubis,  produces  an  indefinable  discom- 
fort. Care  should  be  taken  to  exclude  a  tender  left  lobe  of 
the  liver,  a  filled  or  an  inflated  colon,  and  a  distended  bladder, 
tenderness  over  which  may  be  mistaken  for  sensitive  sympa- 
thetic ganglia.  With  these  may  be  found  other  signs  or 
symptoms  of  neurasthenia,  as  neuralgia,  spinal  points,  head- 
ache, and  insomnia ;  but  none  of  the  signs  enumerated  are 
conclusive,  as  neurasthenia  may  generate  or  may  be  asso- 
ciated with  myasthenia.  The  functional  signs,  however,  are 
distinctive.  In  neurasthenia  gastrica  both  the  mechanical 
and  the  chemical  functions  of  the  stomach  are  normal,  and 
consequently  the  presence  of  gastric  splashing  under  the  con- 
ditions already  given,  and  the  evidences  of  constant  motor 
insufficiency  furnished  by  the  tube  and  by  test-meals,  exclude 
simple  neurasthenia  gastrica  with  certainty. 

The  vertical  displacement  and  the  prolapse  (gastroptosis) 
of  the  stomach  may  be  confounded  with  myasthenia.  The 
dislocations  of  the  stomach  may  be  symptomless  until  some 
complication  develops,  and  the  most  frequent  complications 
are  m3'asthenia  and  motor  insufficiency,  due  to  partial  ob- 
struction. In  vertical  dislocation  the  pyloric  portion  is  dis- 
placed downward  and  to  the  left;  the  percussion  area  of  the 
stomach  does  not  cross  the  median  line,  and  remains  high,  as 
in  health.  In  gastroptosis  the  lesser  curvature  descends,  and 
other  abdominal  viscera  are  usually  also  displaced.  In  both 
forms  of  displacement  the  stomach  may  splash.  The  infla- 
tion of  the  stomach  and  the  other  physical  methods  of  ex- 
amination usually  reveal  clearly  the  position  of  the  stomach. 
It  should  not  be  forgotten  that  the  displaced  stomach  is 
often  myasthenic.  The  abdominal  belt  and  the  water-test, 
and  possibly  visible  peristalsis  and  a  palpable,  firmly  con- 
tracted stomach,  furnish  the  only  means  of  distinguishing 
myasthenic  stagnation  from  the  obstructive  stagnation  pro- 
duced by  displacements  of  the  stomach  or  by  enlargements 
of  the  liver. 

The  differentiation  of  myasthenia  from  pyloric  obstruction 
may  be  difficult.  In  making  this  distinction  the  clinical  his- 
tory may  be  very  valuable  when  it  gives  a  group  of  symp- 
toms characteristic  of  a  disease  which  is  likely  to  produce  an 
obstructing  deformity.  The  most  common  diseases  of  the 
stomach  which  produce  obstruction  are  ulcer  and  carcinoma. 
If  there  be  a  history  of  gastric  hemorrhage,  of  epigastric 
pain  bearing  the  character  of  that  of  ulcer,  and  other  gastric 
symptoms  in  the  characteristic  relation   to  the  ingestion  and 


358  DISEASES  OF  THE  STOMACH. 

the  qualities  of  the  food,  it  is  very  probable  that  the  motor 
insufficiency  is  due  to  obstruction.  The  motor  insufficiency 
of  the  stomach  may  be  due  to  other  diseases  than  that  of  tiie 
stomach  itself,  such  as  duodenal  stenosis,  perigastric  and 
duodenal  adhesions,  the  pressure  of  tumors  and  of  displaced 
organs.  The  obstructed  stomach  contracts  on  its  contents 
and  retracts  when  it  is  empty.  In  marked  contrast  is  the 
weak,  easily  distensible,  slightly  retractile  stomach  of  myas- 
thenia. During  the  performance  of  lavage  in  myasthenia 
the  water  flows  in  rapidly  and  continuously,  a  suction  whirl- 
pool may  be  produced  by  holding  the  funnel  high,  and  the 
outflow  is  slow  and  steady  ;  but  m  obstruction  the  inflow  is 
slow  and  may  temporarily  stop,  and  the  outflow  is  strong  and 
often  in  spurts.  In  myasthenia  expression  is  difficult  and 
always  incomplete  ;  but  in  obstruction  the  greater  portion  of 
the  contents  can  be  easily  removed  by  expression.  The  mus- 
cular layer  of  the  obstructed  stomach,  in  the  effort  to  estab- 
lish compensation,  becomes  hypertrophied,  stronger  than 
normal,  and  the  moderately  filled  organ  may  be  felt  by  the 
educated  fingers  rounded,  sharply  limited,  resistant,  alter- 
nately relaxing  and  contracting.  The  method  of  Dehio 
shows  no  increase  of  normal  distensibility.  Splashing,  if  it 
exist,  is  limited  to  a  small  area  during  the  digestion  of  a 
meal.  After  a  glass  of  water  taken  on  an  empty  stomach, 
splashing  is  often  difficult  to  produce,  is  limited  to  the  area 
of  the  uncovered  triangle,  and  the  gliding  method  of  Glenard 
is  impracticable,  or  reveals  a  firm  stomach  within  the  normal 
boundaries  and  with  walls  brought  in  contact  with  difficulty. 
In  favorable  cases  with  thin  and  relaxed  abdominal  walls, 
peristalsis,  and  sometimes  antiperistalsis,  may  be  visible  dur- 
ing the  digestive  period.  Unless  the  stomach  is  displaced  or 
is  physiologically  large,  it  remains  within  its  normal  bounda- 
ries, both  when  full  and  when  emj^ty.  The  healthy  and 
physiologically  large  stomach  secretes,  digests,  and  empties 
itself  in  a  normal  manner.  [For  a  full  discussion  of  the  differ- 
entiation of  obstructive  stagnation  and  myasthenic  stagnation 
see  the  article  on  obstruction  of  the  pylorus,  where  the  differ- 
ential value  of  the  water-test  is  also  made  clear.] 

Motor  insufficiency  is  one  of  the  earliest  and  most  constant 
signs  of  carcinoma  of  the  stomach.  It  may  be  due  to  pyloric 
obstruction,  to  infiltration  of  the  muscular  layer,  to  edema 
and  malnutrition  from  obstruction  of  the  venous  and  lym- 
phatic circulation,  and,  probably,  also  to  reflex  nervous  in- 
fluences. Myasthenia  is  very  slow,  often  stationary,  in  its 
course,  occurs  at  all  ages,  is  amenable  to  treatment,  when 


MYASTHENIA   GASTRICA.  359 

simple  is  without  deleterious  influence  on  nutrition,  and  pre- 
sents a  normal  series  of  secretory  and  bacteriological  signs 
in  marked  contrast  with  those  of  carcinoma.  Cancer  is  rap- 
idly progressive ;  is  most  frequent  after  forty ;  is  only  tempo- 
rarily influenced  by  treatment ;  causes  progressive  emaciation 
and  loss  of  strength,  with  blood  and  urine  changes;  may  be 
accompanied  by  transient  edema  of  the  lower  extremities; 
by  enlargement  of  the  inguinal  and  supraclavicular  glands, 
by  secondary  nodules  in  the  liver,  and  by  a  palpable  tumor. 
If  the  cancer  involves  the  stomach,  the  chemical  and  bacteri- 
ological signs  are  distinctive ;  but  these  are  absent  if  the 
motor  insufficiency  is  due  to  compression  by  cancer  of  a 
neighboring  organ,  such  as  the  pancreas  or  the  gall-bladder. 
In  cancer,  particularly  in  the  early  and  obscure  stage,  the 
stomach  is  neither  flabby  nor  easily  distensible  as  in  myas- 
thenia. 

Chronic  asthenic  gastritis  is  rarely  accompanied,  except 
in  the  advanced  stage  of  some  cases,  by  motor  insufficiency. 
Consequently,  none  of  the  physical  and  functional  signs 
of  myasthenia  exist  in  this  disease.  The  stomach  is  normal 
in  size;  there  is  no  abnormal  splashing;  the  hydrochloric 
secretion  and  the  ferments  are  constantly  diminished  ;  there  is 
always  an  excess  of  mucus;  after  a  test-breakfast  the  con- 
tents are  thick  and  contain  little  fluid,  and  two  glasses  of 
water  are  evacuated  from  the  stomach  within  two  hours. 
Cases  of  chronic  asthenic  gastritis  which  have  become  com- 
plicated by  motor  insufficiency  do  not  differ  materially  from 
myasthenia  which  has  become  complicated  by  asthenic  gas- 
tritis, except  in  their  etiology  and  evolution. 

A  stomach  of  any  size  may  become  myasthenic,  but  a 
large  stomach  will  not  be  confounded  with  a  myasthenic 
stomach,  except  when  the  diagnosis  is  based  on  the  position 
of  the  greater  curvature,  a  mistake  which  is  sometimes  made' 
by  the  inexperienced.  Myasthenic  stagnation  is  easily  dis- 
tinguished from  both  myasthenic  and  obstructive  retention 
by  the  presence  of  food  in  the  stomach  before  breakfast  after 
the  Boas  evening  meal  and  by  the  active  fermentation  which 
exists  in  retention. 

Treatment. — The  prophylaxis  of  myasthenia  is  very  im- 
portant. During  convalescence  from  acute  diseases,  and  dur- 
ing the  course  of  exhausting  diseases,  the  diet  should  always 
be  regulated  so  as  to  favor  the  weak  gastric  muscle,  and 
means  should  be  adopted  to  preserve  and  to  revive  its  power. 
If  there  be  a  hereditary  predisposition,  digestive  hygiene 
should    be    regulated    so    as    to    require    no    extraordinary 


360  DISEASES  OF  THE  STOMACH. 

mechanical  work  of  the  stomach,  and  the  neuromuscular 
system  should  be  developed  by  a  properly  regulated  life. 
The  same  prophylactic  measures  are  an  essential  part  of  the 
treatment  of  all  diseases  of  the  stomach  likely  in  their  course 
to  become  complicated  by  myasthenia,  the  development  of 
which  marks  a  danger-point  in  their  evolution  and  often 
necessitates  a  complete  change  of  the  treatment. 

The  treatment  of  the  established  disease  is  simple,  and  the 
object  is  clearly  defined  by  its  pathology.  The  weak  muscle 
must  be  fcivored  in  its  work,  its  strength  must  be  developed, 
and  enough  food  should  be  taken  to  keep  the  body  well 
nourished. 

A  proper  diet  is  consequently  a  matter  of  the  first  impor- 
tance. The  food  should  be  nutritious,  in  small  bulk,  and 
indifferent  in  its  action  on  the  stomach.  Some  authorities 
claim  that  a  dry  diet  is  essential  and  best,  and  recommend 
frequently  repeated  meals  ;  but  in  our  experience  a  glass  of 
fluid  is  an  advantage,  and  the  stomach  regains  its  tone  more 
rapidly  when  allowed  as  long  an  interval  of  rest  as  possible. 
In  the  severe  form  it  is  not  advisable  to  give  frequent  meals  ; 
the  stomach  should  be  given  time  to  empty  itself  before  intro- 
ducing more  food  into  it.  An  increased  number  of  meals 
necessitates  an  approximation  of  the  meals,  and  this  disad- 
vantage may  outweigh  the  benefit  derived  from  the  diminu- 
tion of  the  quantit)^  of  each  meal.  The  one  or  the  other 
method  may  suit  a  particular  case  best,  and  it  may  be  wise 
to  control  the  plan  of  feeding  adopted  by  daily  examinations 
and  by  the  frequent  use  of  the  stomach-tube.  It  is  best, 
however,  when  the  food  is  badly  utilized  by  the  intestines,  or 
when  the  stomach  is  capable  of  managing  only  a  small  quan- 
tity, to  divide  the  total  quantity  of  food  required  for  the 
twenty-four  hours  into  four  equal  parts,  to  be  given  five 
hours  apart.  Overtaxing  the  stomach  is  thus  avoided  and 
an  interval  of  repose  is  secured  between  the  meals. 

An  excess  of  sweets  and  fats  is  injurious  in  myasthenia. 
The  one  increases  the  quantity  of  secretion  and  is  liable, 
on  account  of  the  stagnation,  to  induce  fermentation  ;  and 
the  other  delays  the  evacuation  of  the  stomach.  But  fat 
in  the  form  of  fresh  butter  should  be  given  in  sufficient  quan- 
tity to  meet  the  requirements  of  nutrition,  and  for  theoretical 
reasons  is  too  often  forbidden,  for  exi)erience  shows  that  it 
may  be  well  borne,  and  this  rich  force-producing  and  nerve- 
building  food  is  essential  in  moderate  quantity.  It  is  custo- 
mary to  exclude  sweets,  but  the  exclusion  of  this  valuable 
class  of  foods  is  also  an  error,  for  it  is  only  necessary  to  limit 


MYASTHENIA    GASTRIC  A.  36 1 

the  quantity  and  to  select  the  most  digestible  of  the  foods 
which  contain  sugar.  The  fear  of  fermentation  in  stagnation 
myasthenia  is  not  well  founded,  and  it  is  rarely  necessary  to 
do  more  than  to  select  the  fats  and  sweets  and  to  forbid  their 
excessive  consumption. 

The  diet  should  not  be  exclusive,  but  mixed,  and  should 
consist  of  a  combination  of  finely-divided,  tender,  and  lean 
meats  ;  fish  ;  the  more  nutritious  and  easily  digestible  cereals, 
such  as  rice  and  the  preparations  of  wheat  and  h6miny  or 
cornmeal  mush,  thoroughly  cooked;  a  small  quantity  of 
vegetables  which  do  not  possess  a  great  deal  of  waste  matter  ; 
fresh  butter ;  and  some  sweets.  Preparations  of  eggs  may 
also  be  allowed,  but  too  much  of  the  yolk  will  not  be 
well  borne.  An  exclusive  or  chiefly  milk  diet  is  often  pre- 
scribed, but  is  an  experiment,  and,  on  account  of  the  large 
quantity  required  to  support  nutrition,  is  very  objectionable; 
but  milk,  when  well  borne,  may  be  permitted  as  a  drink.  A 
cup  of  coffee  once  or  twice  a  day  may  not  be  injurious. 
Tea,  cocoa,  and  chocolate  should  be  prohibited,  but  Haus- 
waldt's  "  Vigor  Chocolate  "  may  be  tried.  A  small  quantity 
of  alcohol,  if  the  patient  is  accustomed  to  its  use,  may  be 
permitted  at  meal-time,  and  will  usually  promote  both  absoi"p- 
tion  and  the  evacuation  of  the  stomach.  A  little  pure  old 
whisky  or  brandy  may  be  taken,  well  diluted,  or  a  light  wine 
may  be  permitted  ;  but  often  no  drink  will  be  found  to  agree 
better  than  a  glass  of  plain  water,  just  cold  enough  to  be  re- 
freshing. A  small  quantity  of  ripe,  seedless  fruit  should 
not  be  injurious. 

This  is  the  diet  of  simple  myasthenia  with  stagnation : 
Small  in  bulk  and  nutritious  ;  finely  divided  ;  mixed  ;  very  little 
fruit  and  vegetables  ;  a  moderate  quantity  of  sweets  and  fats  ; 
nitrogenous  foods  and  cereals  as  freely  as  in  health  ;  and  a 
limited  quantity  of  fluid.  We  are  not  advocates  of  a  dry 
diet  in  myasthenia,  and  at  least  three  pints  of  fluid  should  be 
taken  in  the  twenty-four  hours.  The  gastric  splashing  has 
led  logically  to  the  recommendation  of  a  dry  diet.  This  we 
believe  to  be  a  mistake,  and  consequently  permit  a  glass  of 
fluid  (water,  coffee,  meat  broths,  possibly  milk,  or  "Vigor 
Chocolate")  with  each  meal.  Two  or  three  more  glasses  of 
fluid  must  be  given  during  the  twenty-four  hours,  at  such 
times  as  will  interfere  the  least  with  digestion,  or  it  may  be 
advisable  to  give  part  of  the  required  fluid  by  rectum. 

In  the  erect  position  the  contents  of  the  myasthenic  stom- 
ach weigh  down  and  distend  the  pyloric  portion,  and  may 
produce  an   incomplete  obstruction   of  the  duodenum  at  its 


362  DISEASES  OE  THE  STOMACH. 

point  of  attachment  to  the  vertebral  column.  It  is  not  the 
liquid  alone,  but  the  weight  of  the  total  gastric  contents  and 
the  erect  position  which  add  to  the  labors  of  the  weak  mus- 
cle. The  myasthenic  who  overloads  his  stomach  and  goes 
to  work  or  exercise  immediately  after  meals  is  not  likely  to 
do  well.  If  the  mechanical  work  required  of  the  stomach  in 
a  particular  case  is  greater  than  it  can  perform,  the  insuffi- 
ciency will  increase  and  retention  will  result.  One  or  two 
hours'  rest  after  meals  is  wise  and  beneficial. 

Where  the  myasthenia  is  complicated,  the  chemical  and 
bacteriological  signs  will  require  consideration  in  selecting 
the  diet.  These  complications  or  accidental  associations  are 
fermentation,  excessive  secretion  (adenohypersthenia),  gas- 
tritis, and  intestinal  diseases.  It  is  still,  however,  the  func- 
tional power  of  the  stomach  and  intestines  and  the  physio- 
logical action  of  the  food  which  decide  the  diet  after  the 
possible  excessive  or  peculiar  germ  growth  is  arrested,  A 
diet  so  regulated  as  to  support  nutrition  and  to  diminish  the 
mechanical  work  of  the  stomach  places  the  organ  in  a  favora- 
ble condition  for  regaining  its  lost  muscular  power.  But 
other  remedies  may  also  be  employed  to  strengthen  the  weak 
muscle.  The  most  important  of  these  are  exercise,  massage, 
electricity,  hydrotherapy,  and  a  few  drugs. 

The  principle  which  should  regulate  the  strength  and  dose 
of  these  remedies  may  be  the  contrary  of  that  which  usually 
guides  practice.  The  greater  the  myasthenia,  the  milder  and 
less  excitant,  in  some  cases,  should  be  the  remedy.  The 
weak  gastro-intestinal  muscle  may  be  excessively  irritable, 
and  overexcitation  or  stimulation  does  harm.  This  injuri- 
ous action  is  clearly  demonstrated  by  the  effect  of  a  strong 
purgative  m  well-marked  myasthenia  of  the  colon,  producing 
colic  and  localized  contractions  persisting  for  hours.  No 
remedy  which  strains  or  exhausts  a  weak  muscle  can  increase 
its  strength.  The  dose  of  the  muscular  excitant  must  fall 
short  of  producing  irritable  spasm  and  exhaustion. 

The  exercise,  which  is  best  taken  in  the  open  air,  should 
not  begin  earlier  than  one  hour  after  meals,  and  should  always 
be  moderate,  so  that  the  slight  sense  of  fatigue  disappears 
after  a  few  minutes'  rest. 

Abdominal  massage  is  a  remedy  of  value.  If  the  stagna- 
tion is  pronounced,  it  may  be  employed  late  in  the  evening — 
four  hours  after  meals — to  empty  the  stomach,  the  organ  being 
left  contracted  under  the  influences  of  the  skin  reflexes  ex- 
cited by  circular  movements  of  the  tips  of  the  fingers  around 
the  umbilicus  and  over  the  stomach.     It  is  often  advisable  to 


MYASTHENIA    GASTRICA.  363 

massage  the  abdominal  muscles,  but  the  intestines  should  be 
left  alone  to  digest  and  to  absorb  their  contents  during  the 
night.  The  general  abdominal  massage,  if  indicated  by  in- 
testinal stagnation,  should  be  performed  in  the  morning,  fast- 
ing or  after  the  administration  of  a  glass  of  water.  The  best 
methods  of  using  water  in  the  treatment  of  myasthenia  are 
the  intragastric  spray  and  the  Scottish  douche,  in  the  manner 
recommended  to  tone  the  abdominal  sympathetic.  If  the 
patient  tolerates  the  tube,  the  intragastric  douche  with  plain 
water  will  be  found  valuable,  particularly  in  the  cases  where 
suggestion  is  likely  to  prove  a  remedy  of  value.  The  tonic 
influence  of  a  shower-bath  is  thus  brought  directly  to  the 
gastric  wall.  The  intragastric  spray  may  be  employed  twice 
a  week,  in  the  morning  before  breakfast,  care  being  taken  to 
avoid  overloading  the  stomach  with  water  and  to  leave  the 
organ  empty.  There  is  in  the  stagnation  form  of  myasthenia 
no  indication  for  stomach  washing. 

Electricity  may  also  be  often  employed  with  advantage, 
strong  currents  of  low  density  being  most  beneficial.  Intra- 
gastric faradism  and  cathodal  galvanism  are  the  best  methods, 
and  minute  directions  for  using  electricity  to  tone  the  stomach 
will  be  found  in  the  section  on  General  Medication. 

A  few  drugs  are  of  great  value  in  the  treatment  of  myas- 
thenia. Of  these,  strychnin  deservedly  holds  the  first  place. 
Ergot  is  also  valuable  when  well  borne.  Hydrastinin  muri- 
ate is  often  beneficial.  Quinin  (alkaloid  preferable  to  its 
salts)  is  almost  as  valuable  as  strychnin.  The  prolonged 
use  of  ipecac  in  very  small  doses  is  also  beneficial.  Two  or 
more  of  these  drugs  may  be  given  combined.  The  other 
medicines  are  those  commonly  used  to  control  gross  symp- 
toms. 

Constipation  may  be  a  troublesome  association,  but  is  usu- 
ally relieved  by  a  proper  diet,  by  massage,  by  electricity,  by 
gluten  suppositories,  by  glycerin  suppositories,  and  by  the 
general  hygienic  remedies  directed  against  the  gastric  myas- 
thenia. An  occasional  injection  of  water,  or  water  and  a 
teaspoonful  of  glycerin,  may  be  required.  Cascara  sagrada 
in  barely  efficient  doses  (combined  with  hyoscyamus  or  bella- 
donna) may  be  prescribed.  A  pinch  of  Turkish  rhubarb 
after  the  evening  meal  may  be  all  that  is  needed.  But  the 
time  required  for  the  patient  to  get  well  is  prolonged  by  the 
use  of  purgatives,  and  no  good  is  done  the  myasthenic  stom- 
ach by  the  frequent  employment  of  laxatives. 


364  DISEASES  OF  THE  STOMACH. 


2.   MYASTHENIA  WITH   RETENTION. 

Stagnation  myasthenia  may  remain  stationary  for  a  long 
period,  but  its  inherent  tendency  is  to  increase.  Retention 
niN'asthenia  is,  consequently,  the  natural  sequence  of  the 
stagnation  form.  The  prolongation  of  digestion,  which  neces- 
sarily results  from  stagnation  myasthenia,  increases  the 
mechanical  work  which  the  stomach  has  to  perform  and 
requires  abnormal  endurance  of  its  weak  muscle.  The  nor- 
mal stomach  would  hypertrophy  under  the  increased  work 
demanded  by  the  prolongation  of  digestion  and  of  secretion, 
but,  unfortunately,  the  myasthenic  stomach  does  not ;  its 
task  must  be  lightened  before  the  weak  muscle  will  begin  to 
recuperate.  Furthermore,  the  myasthenic  stomach  creates 
new  difficulties  for  itself.  Normally,  the  pyloric  end  of  the 
stomach,  as  it  becomes  distended  by  the  contents  of  the 
stomach  forced  into  it  by  peristalsis,  extends  downward  and 
to  the  right,  and  is  elevated  by  rotation  forward  and  upward, 
thus  relaxing  the  gastrohepatic  ligament  and  making  it  easy 
for  fluids  to  pass.  In  myasthenia  the  enlarged  pyloric  antrum 
simply  descends  in  the  abdomen,  tightens  the  gastrohepatic 
ligament,  and  produces  an  angular  constriction,  which  renders 
the  evacuation  of  the  stomach  more  difficult.  If  the  patient 
be  emaciated,  or  if  abdominal  tension  is  low,  the  production 
of  the  duodenopyloric  constriction  is  facilitated.  In  spite  of 
this  difficulty,  and  in  spite  of  the  increase  of  mechanical  work, 
the  stagnation  myasthenia  may  persist  for  a  long  time  without 
progressing  to  a  severer  stage,  or  retention  may  eventually 
result.  The  advent  of  retention  is  favored  b\'  a  ver}'  large 
meal,  by  excesses,  by  fatigue,  by  enlargement  of  the  liver, 
and  by  acute  or  chronic  exhausting  diseases. 

Clinical  Description. — When  the  myasthenia  becomes  so 
great  that  the  stomach  never  completely  evacuates  its  con- 
tents into  the  duodenum,  the  symptomatology  changes.  To 
the  digestive  symptoms  proper  to  myasthenia  are  added  those 
due  to  the  retention  and  the  fermentation. 

The  appetite  is  usually  poor,  and  decreases  with  the  activity 
of  fermentation.  Thirst  may  become  intense,  but  is  in  direct 
relation  with  the  sy.stem's  loss  of  fluid  by  retention  and  by 
vomiting.  The  patient,  after  a  restless  night,  awakes  in  the 
morning,  commonly  with  a  headache,  depressed  and  tired. 
Immediately  after  meals  the  stomach  feels  heavy  and  full  and 
the  abdomen  becomes  flatulent  and  distended.  The  flatu- 
lency increases  with  the  movements  of  the  digestive  tube,  and 


MYASTHENIA    GASTRICA.  365 

large  quantities  of  gas  are  removed  by  repeated  belching, 
often  bringing  a  small  quantity  of  a  sour  and  bitter  fluid  into 
the  mouth.  There  is  constant  nausea,  and  sometimes  vertigo, 
if  there  is  butyric  fermentation  or  putrefaction.  The  products 
of  fermentation  produce  sometimes  a  burning,  local  pain, 
and  if  active  fermentation  continues  in  the  intestines  it  pro- 
duces also  colic,  and,  rarely,  diarrheal  movements  ;  but  ob- 
stinate constipation  is' the  rule  in  myasthenia  with  retention. 
During  the  digestive  period  the  headache  and  nervous 
symptoms  increase.  The  symptoms  diminish  after  a  number 
of  hours,  but  there  is  no  interval  of  gastric  repose  or  comfort. 
From  meal  to  meal  the  retained  contents,  in  active  fermenta- 
tion, accumulate  in  the  stomach,  until  about  every  second  or 
fourth  day  the  overloaded  organ  is  relieved  by  copious,  effort- 
less vomiting,  occurring  often  without  nausea.  The  system 
is  thus  robbed  of  its  nourishment  by  vomiting,  and  by  fer- 
mentation beginning  in  the  stomach  and  extending  to  the 
intestines,  and  is  also  slowly  poisoned  by  germ  products. 

Vomiting,  however,  is  not  so  common  a  symptom  of  myas- 
thenic retention  as  of  that  due  to  pyloric  obstruction,  and  is 
usually  incomplete,  less  copious,  and  more  apt  to  occur  three 
or  four  hours  after  a  meal  than  at  night.  The  vomit  consists 
of  a  brownish  mixture  of  a  bad  odor,  like  that  of  "dead" 
yeast  fermentation,  very  acid,  often  bitter,  containing  mucus 
and  sometimes  blood  and  bile,  and  separates,  on  standing,  into 
three  distinct  layers,  the  upper  being  fatty  and  foamy,  the 
middle  fluid  and  cloudy,  and  the  lower  consisting  of  solid 
residue  of  food  mixed  with  germs  and  giving  off  bubbles  of 
gas,  often  carrying  with  them  on  their  way  to  the  top  layer 
little  particles  of  food.  The  vomiting  becomes  less  and  less 
frequent  as  the  myasthenia  increases,  but  when  it  occurs  tem- 
porary relief  follows. 

Emaciation  is  a  constant  symptom  of  myasthenia  with  re- 
tention, and  is  due  partly  to  enforced  inanition.  The  intes- 
tines can  not  compensate  the  inefficient  stomach,  because  the 
fermenting  mass,  in  part  delivered  to  it,  is  neither  digestible 
nor  nutritious,  and  disorders  the  functions  of  the  intestines. 
Gastric  absorption  decreases  with  the  overdistention  of  the 
stomach,  and  many  of  the  so-called  auto- intoxication  symp- 
toms are  due  to  the  deficient  supply  of  food  and  water. 

The  functions  of  the  intestines  are  always  disordered  in 
myasthenic  retention.  If  the  vomiting  is  complete  it  is  often 
followed  by  improvement  of  the  intestinal  fermentation  and 
of  flatulency  ;  but  the  constipation  continues  obstinate  and 
the  movements  are   rare,  dry,  and  scybalous.     In  some  cases 


366  DISEASES  OF  THE  STOMACH. 

the  stomach,  irritated  by  the  products  of  active  fermentation, 
empties  its  contents  into  the  intestines  and  produces  a  fer- 
mentative diarrhea.  Often  the  intestines  are  also  myasthenic, 
and,  as  a  consequence,  enteritis  membranacea  may  eventually 
develop. 

The  urine  is  always  diminished  in  quantity  in  proportion 
to  the  insufificient  absorption  and  to  the  loss  of  water,  and  it 
is  of  high  specific  gravity.  Consequently,  the  quantity  of 
urine  passed  in  the  twenty-four  hours  may  be  taken  as  a 
rough  measure  of  the  degree  of  retention,  notice  bein<j  taken 
of  the  quantities  of  water  ingested  and  vomited  or,  rarely, 
eliminated  by  diarrhea.  The  chlorids  are  diminished  and 
the  phosphates  are  increased  and  precipitated  in  large  quan- 
tities on  heating.  If  there  be  excessive  secretion,  the  urine 
may  present  all  the  characteristics  found  in  hypersthenic  gas- 
tritis. Rapid  or  severe  emaciation  may  be  accompanied  b\' 
acetonuria. 

A  large  number  of  general  symptoms  and  diseases  of 
other  organs  results  directly  and  indirectly  from  gastric  reten- 
tion. Some  find  a  convenient  explanation  of  these  in  refle.x 
action  ;  others  attribute  them  to  the  subnutrition,  the  defi- 
ciency of  water,  the  disordered  metabolism,  and  the  dimin- 
ished power  of  resistance  of  the  organism  ;  and  still  others, 
adopting  the  theory  of  Bouchard,  explain  their  genesis  by 
auto-into.xication.  The  germ  products  absorbed  from  the 
digestive  tube  doubtless  play  an  important  pathogenic  part, 
and  produce  directly  many  of  the  general  sj'mptoms,  but  it 
can  not  be  shown  that  more  than  a  part  of  these  products 
are  formed  in  the  stomach. 

The  list  of  these  secondary  troubles  is  a  ver\'  long  one. 
The  liver  is  frequently  periodically  congested.  There  may 
also  be  attacks  of  icterus  without  alteration  of  the  color  of 
the  stools.  Palpitation,  arrhythmia,  tachycardia,  reduplication 
of  the  second  sound,  are  common  heart  disorders,  the  action 
of  this  organ  (right  ventricle)  being  also  at  times  mechani- 
cally interfered  with  by  the  presence  of  the  distended  stomach 
and  by  contraction  of  the  pulmonary  arterioles.  Bronchitis 
occurs  as  frequently  as  inflanmiation  of  other  mucous  mem- 
branes. Urticaria,  acne,  pityriasis  versicolor,  erythema,  and 
eczema  are  some  of  the  skin  affections  associated  with  myas- 
thenic retention.  The  nervous  symptoms  are  very  numerous 
— disorders  of  the  special  senses  and  of  speech,  affections  of 
memory,  hypochondriasis,  tetany,  muscular  cramps;  attacks 
beginning  with  restlessness,  jactitation,  slight  general  convul- 
sions, and  accompanied  b\' d\-spnea  and  somnolence,  ending  in 


AIYASriJENIA    GASTRIC  A.  367 

coma.  Some  claim  rickets  to  be  the  result,  while  Bouchard 
describes  an  enlargement  of  the  second  phalangeal  joints  as  a 
nutritive  disorder  which  exists  only  in  association  with  gastric 
retention.  That  auto-intoxication  may  be  the  possible  cause 
of  these  numerous  troubles  may  be  admitted ;  but  a  possible 
explanation  is  not  necessarily  always  the  true  one,  and  it  is 
certain  that  they  have  not  been  proven  to  result  from  gastric 
retention. 

The  Objective  Signs. — The  signs  furnished  by  the  examina- 
tion are  those  of  myasthenia,  of  retention,  and  of  fermentation. 
The  signs  of  myasthenia  have  been  given  in  the  description 
of  the  stagnation  form  or  period  of  the  disease.  The  second 
clinical  form  or  period  is  characterized  by  the  signs  of  reten- 
tion and  of  fermentation. 

The  patient  is  emaciated,  the  skin  is  dry  and  rough,  and 
the  secretions  are  thickened;  the  extremities  are  often  cold, 
and  the  fingers  may  show  the  nodosities  of  Bouchard. 

The  physical  examination  usually  reveals  a  flabby  stomach 
of  large  size.  If  the  organ  is  filled,  the  epigastrium  and  the 
left  hypochondrium  are  prominent,  and  the  greater  curvature 
may  often  be  seen  and  felt  running  lower  and  to  the  right  of 
the  normal  limits,  splashing  always  under  the  same  conditions 
as  in  myasthenia  with  stagnation.  A  normal  size  of  the 
stomach  does  not  exclude  either  form  of  the  disease.  Infla- 
tion may  be  employed  to  locate  and  to  define  more  accurately 
the  boundaries  of  the  stomach,  revealing  or  excluding  a  dis- 
placement. An  important  inspection  sign  is  self-inflation  of 
the  stomach,  when  the  viscus  may  be  seen  slowly  to  distend 
with  gas  and  somewhat  abruptly  to  collapse  with  the  escape 
of  gas  through  the  pylorus.  Peristalsis  is  visible  only  when 
there  is  obstruction  to  the  evacuation  of  the  stomach,  and  is 
not  a  sign  of  myasthenia.  On  placing  the  stethoscope  over 
the  stomach,  intragastric  bubbling  can  often  be  heard.  Both 
the  self-inflation  and  the  crackles  are  signs  of  gas-forming 
fermentation,  and  when  present  in  the  morning  before  break- 
fast are  pathognomonic  of  retention  and  of  fermentation. 

Another  physical  sign  of  retention  is  gastric  splashing  in 
the  morning  before  anything  has  been  taken  into  the  stomach. 
This  sign  is  never  absent  in  myasthenic  retention,  but  is  also 
found  in  continuous  secretion. 

The  pathognomonic  sign  of  gastric  retention  is  the  presence 
of  a  noteworthy  quantity  of  food  in  the  stomach  in  the  morning 
after  a  test-supper  (Boas).  To  measure  the  degree  of  motor 
insufficiency  the  stomach  should  be  washed  out  before  the 
supper  is  eaten.     The  quantity  of  food  in  the  stomach  on  the 


368  DISEASES  OF  THE  STOMACH. 

following  morning  is,  then,  proportionate  to  the  motor  insuf- 
ficiency. 

The  contents  of  the  stomach,  removed  by  vomiting  or  by 
the  tube,  present  physical,  chemical,  and  bacteriological  pro- 
perties characteristic  of  retention.  The  odor  is  sour,  dead, 
often  rancid.  The  total  acidity  is  always  high,  consisting  of 
the  free  and  the  combined  acids  of  secretion  and  fermenta- 
tion. On  standing,  it  separates  into  three  layers,  with  visi- 
ble gas  formation.  The  gases  consist  of  those  of  swallowed 
air,  of  fermentation,  and  of  putrefaction,  including  some- 
times H  and  HoS.  Sarcinae,  yeast,  and  numerous  bacteria 
are  found.  If  the  stomach  is  washed  out  and  a  test-break- 
fast given,  we  may  obtain  the  secretory  and  digestive  signs 
of  hyperchylia  or  of  a  complicating  gastritis,  plus  fermenta- 
tion. Lactic  acid  is  frequently  found  in  the  contents  where 
no  free  HCl  is  present;  but  lactic  acid  is  not  formed  under 
the  conditions  of  the  Boas  cancer  test.  Gas  formation  is  active 
in  the  fermentation  tubes  filled  with  the  unfiltered  and  sweet- 
ened contents  of  the  stomach. 

Diagnosis. — The  objective  signs  of  gastric  retention  are  so 
characteristic  that  the  diagnosis  of  the  condition  is  easy.  It 
is  often  confounded  with  the  stagnation  form  of  the  disease, 
both  possessing  in  common  the  signs  of  myasthenia;  but 
on  account  of  the  different  treatment  and  prognosis  it  is 
practically  important  that  the  two  forms  should  be  sharply 
separated.  The  one  is  benign,  local,  unaccompanied  by  ema- 
ciation or  auto-into.xication,  the  stomach  always  succeeding 
in  completely  empt\'ing  itself  and  in  delivering  to  the  body 
the  required  quantity  of  nutriment  of  all  sorts.  The  other 
is  a  starving  and  poisoning  disease,  accompanied  by  emacia- 
tion, auto-intoxication,  morning  retention,  and  actix'e  gastric 
fermentation,  the  stomach  withholding  the  amount  of  both 
food  and  water  necessary  to  maintain  nutrition.  The  physi- 
cal, functional,  and  bacteriological  signs  render  it  possible  to 
determine  accurately  where  the  one  begins  and  the  other 
ends.  But  gastric  retention  is  not  synonymous  with  myas- 
thenic retention  ;  consequently,  myasthenic  retention  must 
be  distinguished  from  the  other  diseases  which  are  accom- 
panied by  gastric  retention. 

Differential  Diagnosis. — Motor  insufficiency  of  the  .stom- 
ach may  be  due  to  increased  resistance  to  the  evacuation  of 
the  stomach,  to  diminution  of  the  evacuating  power  of  the 
stomach,  or  to  an  abnormal  amount  of  work  to  be  accom- 
plished. Increased  resistance  to  evacuation  is  the  result  of 
obstruction.     Diminution   of  the  evacuating   power   may  be 


MYASTHENIA    GASTRIC  A.  369 

produced  by  myasthenia,  by  cancerous  or  inflammatory  infil- 
tration of  the  muscular  layer  of  the  stomach,  and  by  gastro- 
plegia.  The  amount  of  work  may  be  made  abnormal  by  the 
eating  of  a  very  large  meal. 

Now,  gastroplegia  occurs  suddenly,  and  is  usually  the  result 
of  severe  shock  or  of  peritonitis.  It  is  hardly  possible  to 
mistake  this  rare  disease  for  retention  myasthenia.  Acute 
retention  may  be  produced  by  a  very  large  meal,  but  the 
stomach  recovers  its  motor  sufficiency  in  a  few  days  after  the 
large  meal  is  evacuated  into  the  duodenum  or  is  expelled  by 
vomiting.  Very  rarely  death  may  occur,  if  the  greatly  dis- 
tended stomach  can  not  evacuate  the  semi-solid  contents, 
the  whole  mass  acting  as  one  body.  Acute  retention  pro- 
duced in  this  manner  is  not  likely  to  be  confounded  with 
myasthenic  retention. 

Gastric  retention  due  to  myasthenia  is,  then,  to  be  distin- 
guished from  retention  due  to  obstruction,  and  to  cancerous 
or  inflammatory  infiltration  of  the  muscular  layer.  In  only 
one  other  disease  of  the  stomach  is  a  noteworthy  quantity  of 
contents  found  persistently  in  the  stomach  in  the  morning 
before  breakfast,  and  this  disease  is  hypersthenic  gastritis  with 
continuous  secretion,  which  may  be  accompanied  by  pyloric 
obstruction,  or  by  myasthenia,  or  by  myositis,  while  the  motor 
insufficiency  may  be  so  great  as  to  produce  retention,  or  some- 
times only  stagnation. 

It  may  be  very  easy  to  exclude  hypersthenic  gastritis  with 
continuous  secretion.  This  usually  painful  disease  has  many 
<;haracteristic  symptoms,  as  may  be  seen  by  reading  its  clinical 
description.  Anatomical  signs  may  be  found  in  the  contents 
of  the  stomach  in  this  disease,  such  as  blood,  a  large  quan- 
tity of  mucus,  nuclei  of  white  corpuscles,  and  sometimes 
pieces  of  inflamed  mucous  membrane.  To  distinguish  it 
from  myasthenic  retention  it  is  only  necessary  to  establish 
the  morbid  continuity  of  secretion,  for  myasthenia  with 
secondary  hypersthenic  gastritis  and  continuous  secretion 
does  not  differ  from  hypersthenic  gastritis  accompanied  by 
myasthenia  and  continuous  secretion  except  in  their  preced- 
ing history  and  evolution.  Now,  in  continuous  secretion 
the  stomach  may  or  may  not  retain  food.  If  it  does  not  retain 
food  (coarse,  finely  divided,  or  in  digestive  solution),  a  note- 
worthy quantity  of  digestive  fluid  (more  than  twenty  c.c.)  in 
the  stomach  before  breakfast  makes  it  clear  that  secretion  is 
continuous.  If  it  does  retain  food,  it  is  necessary  to  wash  out 
the  stomach  most  thoroughly  in  the  evening.  It  maybe  very 
difficult  to  cleanse  the  stomach  thoroughly,  and  it  is  some- 
24 


370  DISEASES  OF  THE  STOMACH. 

times  wise  to  wash  out  the  stomach  in  the  evening  and  twice 
on  the  following  day,  during  which  time  the  patient  is  nour- 
ished exclusively  by  rectum,  water  only  being  permitted  by 
mouth.  On  the  following  morning  before  breakfast  the  con- 
tents of  the  stomach  are  removed.  If  there  is  continuous 
secretion,  the  stomach  will  contain  more  than  twenty  c.c.  of 
gastric  juice.  The  total  contents  of  the  stomach  should  be 
estimated  by  the  acidity  method  of  Mathieu  or  by  using  the 
one  per  cent,  solution  of  sugar.  The  properties  of  the  morn- 
ing contents  may  sometimes  make  the  differentiation  clear 
without  the  employment  of  lavage,  as  stated  in  the  following 
propositions : 

1.  If  lavage  has  not  been  practised  after  dinner  on  the  pre- 
ceding evening,  and  if  the  morning  contents  contain  no  visible 
remnants  of  food,  nor  deposit  a  flocculent  sediment  which  the 
microscope  shows  to  be  composed  of  particles  of  food,  nor 
give  on  analysis  a  noteworthy  quantity  of  combined  HCl, — 
there  is  no  myasthenic  retention,  nor  food  retention  from  any 
cause  ;  but  if  the  stomach  contains  more  than  twenty  c.c.  of  a 
digestive  fluid  there  is  continuous  secretion. 

2.  The  morning  contents  in  uncomplicated  continuous 
secretion  are  never  more  acid  than  the  contents  after  the 
test-breakfast.  If  the  acidity  (H  -f  C)  of  the  morning  con- 
tents is  greater  than  that  of  the  digestive  contents  there  is 
retention. 

3.  If  the  lines  which  represent  the  quantity  of  free  (H)  and 
of  combined  (C)  hydrochloric  acid  during  the  evolution  of  the 
digestion  of  the  test-breakfast  undergo  sudden  rises  and  falls, 
there  is  motor  insufficiency,  for  the  rises  and  falls  are  due  to 
the  irregular  evacuation  of  the  contents  (obstruction)  or  to 
the  infrequency  of  evacuation  efforts  (myasthenia).  If  con- 
tinuous secretion  is  not  associated  with  motor  insufficiency 
during  the  period  of  decline  of  the  digestion  of  the  test- 
breakfiist,  the  liquid  contents  are  excessive,  and  contain  free 
HCl  and  chlorids,  but  very  little  combined  HCl. 

4.  Whenever,  in  the  ordinary  course  of  events  and  without 
previous  evening  lavage,  the  stomach  contains  in  the  morning 
before  breakfast  a  very  large  quantity  of  secretion  but  no 
coarse  particles  of  food,  the  continuous  secretion  is  accom- 
panied by  motor  insufficiency,  due  to  weakness  or  disease  of 
the  muscular  layer,  unless  the  examination  has  been  made 
during  a  "  secretory  crisis." 

5.  In  continuous  secretion  without  food  retention,  the 
morning  accumulated  secretion  does  not  produce  gas  forma- 
tion when  tested  (unfiltered  and  sweetened)  in  the  fermenta- 
tion tubes. 


MYASTHENIA    GASTRIC  A.  37 1 

When  continuous  secretion  exists — and  its  existence  is 
proven  by  the  continuance  of  gastric  secretion  after  the  stom- 
ach has  been  completely  relieved  of  all  food  by  lavage,  aided, 
if  need  be,  by  fasting — to  such  a  degree  of  activity  as  to  per- 
mit the  accumulation  of  a  pathological  quantity  of  gastric 
juice  in  the  stomach  before  breakfast,  there  may  or  may  not 
be  food  retention.  If  there  is  retention  of  food,  the  disease 
can  not  be  simple  myasthenia  with  retention,  and  the  diag- 
nostic problem  which  remains  for  solution  is  the  detection  of 
the  cause  of  the  retention  which  is  associated  with  the  con- 
tinuous secretion  of  hypersthenic  gastritis  or  of  paroxysmal 
hyperchylia  gastrica. 

If  continuous  secretion  does  not  exist,  the  retention  of  food 
and  digestive  products  may  be  due  to  myasthenia,  to  obstruc- 
tion, or  to  secondary  disease  (inflammation,  cancerous  degen- 
eration, atrophy)  of  the  muscular  layer.  Consequently,  the 
myasthenic  retention  must  be  distinguished  from  obstructive 
retention,  from  carcinomatous  retention,  and  from  the  motor 
insufficiency  which  complicates  and  results,  very  infrequently, 
from  chronic  gastritis. 

Myasthenic  retention  is  comparatively  rare ;  obstructive 
retention  is  frequent.  A  history  of  ulcer,  or  of  toxic  gastritis, 
or  of  gall-stones  is  in  favor  of  obstruction.  A  history  of 
myasthenic  stagnation,  or  of  an  acute  or  chronic  exhausting 
disease,  and  the  coexistence  of  phthisis  are  in  favor  of  myas- 
thenic retention.  The  presence  of  a  pyloric  tumor  removes  all 
doubt  of  the  cause  of  the  retention. 

The  evolution  of  myasthenia  is  ordinarily  slow,  the  symp- 
toms are  comparatively  mild  in  character,  and  the  quantity  of 
food  retained  is  proportionate  to  the  duration  of  the  disease 
of  the  stomach.  Obstructive  retention  may  develop  rapidly, 
is  ordinarily  a  very  painful  disease,  and  the  quantity  of  food 
retained  is  proportionate  to  the  degree  and  not  to  the  age  of 
the  obstruction. 

If  there  is  gastroptosis,  the  retention  may  be  obstructive  or 
myasthenic.  If  the  retention  is  due  to  traction  on  the  duo- 
denum, support  of  the  stomach  by  an  abdominal  belt  and  rest 
in  the  horizontal  position  during  digestion  will  relieve  the 
retention.  Displacement  of  the  stomach  is  much  more  fre- 
quent in  pyloric  obstruction  (neoplasms)  than  it  is  in  myas- 
thenia. In  pyloric  obstruction  the  displacement  of  the 
stomach  begins  with  the  pyloric  end,  and  the  fundus  of  the 
stomach,  as  a  rule,  does  not  descend.  In  gastroptosis  the 
whole  stomach  descends  in  the  abdomen,  and  the  lesser  curva- 
ture and  the  upper  border  of  the  fundus  are  displaced  down- 


372  DISEASES  OF   THE   STOMACH. 

ward  in  proportion  to  the  gastroptosis.  The  obstructed 
stomach  retains  its  general  form,  which  is  lost  in  myasthenia. 

The  obstructed  stomach  is  enlarged  and  hypertrophied  ; 
reflex  peristalsis  and  contraction  are  strong  and  are  easily 
excited  ;  expression  of  its  contents  presents  no  difficulty,  but 
it  is  very  hard  to  remove  all  the  coarse  particles  of  food  from 
the  stomach  by  lavage.  In  myasthenic  retention  the  stomach 
may  be  large  or  small;  its  wall  is  thin  and  flabby;  reflex  peri- 
stalsis can  not  be  excited  and  is  never  visible  ;  contraction  is 
weak  ;  expression  of  its  contents  is  so  difficult  that  siphonage 
or  suction  must  usually  be  employed  to  obtain  the  contents 
for  analysis ;  and  after  prolonged  lavage  it  is  hardly  possible 
to  get  the  stomach  clean  and  empty. 

In  myasthenic  retention  there  are  no  peristaltic  pains  and 
no  cramps,  and  vomiting  is  infrequent  (overflow),  copious, 
liquid,  and  incomplete.  In  obstructive  retention,  peristaltic 
pains  and  cramps  are  ordinarily  severe,  vomiting  may  be  fre- 
quent, retching,  and  complete,  and  the  vomit  is  thick  and 
contains  plenty  of  coarse  food,  and  sometimes  blood,  nuclei 
of  white  corpuscles,  much  mucus,  and  possibly  pieces  of  a 
tumor  or  of  the  inflamed  mucous  membrane  may  be  found  in 
the  vomit,  in  the  expressed  contents,  or  in  the  wash-water. 

In  myasthenic  retention  the  empty  stomach  does  not  re- 
tract, and  emaciation  is  usually  not  rapid  nor  very  great  so 
long  as  the  stomach  can  furnish  the  system  with  the  required 
quantity  of  water.  In  obstruction  the  empty  stomach  retracts, 
and  emaciation  may  develop  very  rapidly.  The  enlarged, 
hypertrophied,  and  obstructed  stomach  may  not  completely 
retract  when  it  is  empty,  and  the  administration  of  half  a 
glass  of  water  may  make  it  possible  to  produce  splashing  over 
a  very  small  area.  The  splashing  can  not  be  produced  when 
the  stomach  is  full,  for  it  is  then  firmly  contracted  on  its  con- 
tents, except  during  the  short  intervals  of  peristaltic  repose. 
In  myasthenic  retention  the  splashing  sounds  may  be  pro- 
duced at  all  hours,  day  ami  night,  and.  as  the  rule,  after  most 
painstaking  efforts  to  empty  the  stomach  completely  with  the 
tube. 

The  evolution  of  the  digestion  of  the  test-breakfast  is  dif- 
ferent in  the  two  forms  of  retention.  The  test-breakfast 
should  be  preceded  by  thorough  lavage,  and  the  stomach 
should  be  left  as  nearly  empty  as  possible.  In  myasthenia 
the  first  two  stages  of  digestion  may  be  prolonged  or  free 
HCl  mav  appear  earlier  than  in  health,  but  the  quantity  of 
combined  HCl  gradually  accumulates,  and  at  the  end  of  two 
hours  the  stomach  contains  about  as  much,  and   sometimes 


MYASTHENIA    GASTRIC  A.  373 

more,  fluid  than  was  taken  with  the  test-meal.  Some  of  the 
contents  are  evacuated,  but  the  slowly  evacuated  fluid  is 
replaced  by  secretion  during  the  first  two  hours.  In  obstruc- 
tion the  first  two  stages  of  digestion  may  be  nearly  normal, 
but  free  HCl  is  excessive  usually  after  the  first  hour,  and  at 
the  end  of  two  hours  the  stomach  contains  a  thick  mixture  of 
coarse  and  fine  particles  of  bread,  and  usually  an  excessive 
quantity  of  physiological  hydrochloric  acid  (H  -f  C).  Ob- 
structive retention  is  a  retention  preeminently  of  solids,  and 
myasthenic  retention  is  a  retention  preeminently  of  liquids. 
Consequently,  if  two  glasses  of  water  are  given  on  an  empty 
stomach  in  myasthenic  retention,  the  greater  part  of  the  water 
will  still  be  in  the  stomach  after  the  lapse  of  two  hours,  but 
in  obstructive  retention  the  stomach  will  be  empty.  For  the 
same  reason,  in  obstructive  retention  there  is  much  coarse 
food  in  the  early  morning  contents,  but  in  myasthenic  reten- 
tion there  is  some  food  and  a  comparatively  large  quantity  of 
fluid.  In  myasthenic  retention  a  moderately  dry  diet  is  best 
borne  ;  in  obstructive  retention  the  diet  should  be  fluid. 

In  myasthenic  retention  physical  and  mental  fatigue  in- 
crease the  motor  insufficiency  but  have  no  effect  on  obstruc- 
tive retention.  Myasthenic  retention  may  be  relieved  by 
favoring  and  toning  the  stomach  muscle.  Obstructive  reten- 
tion is  persistent  without  surgical  intervention. 

The  differentiation  of  myasthenic  retention  from  retention 
due  to  carcinoma  and  to  advanced  chronic  gastritis  will  pre- 
sent no  difficulty  when  the  characteristic  signs  and  symptoms 
of  these  disorders  are  kept  in  memory.  The  persistent 
functional,  bacteriological,  and  anatomical  signs  of  carcinoma 
and  of  the  terminal  period  of  chronic  gastritis  exclude  readily 
the  retention  due  to  myasthenia  ;  but  chronic  gastritis  and 
myasthenic  retention  (complicated)  may  terminate,  like  carci- 
noma, in  the  complete  destruction  of  the  functions  of  the 
stomach. 

Prognosis. — The  prognosis  of  myasthenia  with  retention 
varies  according  to  the  duration,  the  degree,  and  the  compli- 
cations. If  the  retention  is  not  great,  and  general  nutri- 
tion can  be  maintained  by  the  establishment  of  digestive 
compensation  by  the  intestines,  the  chances  for  a  complete 
cure  are  favorable.  In  many  cases  it  is  only  possible  to 
convert  the  retention  into  the  stagnation  form  of  the  disease 
and  to  maintain  the  body  in  a  fair  nutritive  condition  by 
persistent  and  carefully  regulated  digestive  hygiene.  The 
prospect  is  darker  where  gastritis  coexists,  particularly  the 
hypersthenic  form.     The  prognosis  is  worse  where  the  intes- 


374  DISEASES  OF  THE  STOMACH. 

tines  are  also  diseased,  for  the  insufficiency  of  the  intestines 
determines,  to  a  large  extent,  the  future.  The  quantity  of  urine 
passed  in  twenty-four  hours  and  the  quantity  of  food  retained 
in  the  morning  after  the  test-supper  are  also  prognostic  guides. 
The  situation  is  all  the  more  serious  where  secondary  diseases 
exist,  due  to  auto-intoxication,  or  where  there  is  a  serious 
independent  trouble.  It  is  safe  to  give  a  guarded  prognosis 
in  all  cases,  and  watch  the  results  of  treatment  for  encouraging 
signs. 

Treatment. — The  objects  sought  by  treatment  are  :  (i)  The 
improvement  of  the  motor  function  ;  (2)  the  prevention  of 
starvation;  (3)  the  control  of  fermentation  ;  (4)  the  treatment 
of  the  gross  symptoms,  of  auto-intoxication,  and  of  the  com- 
plications. 

To  increase  the  power  and  the  efficiency  of  the  muscular 
layer,  the  same  remedies  which  are  valuable  in  the  treatment 
of  myasthenia  with  stagnation  may  be  used,  including  mas- 
sage, electricity,  hydrotherapy,  strjxhnin,  quinin,  and  ergot. 
Massage  should  not  be  used  to  evacuate  the  stomach  until  the 
excessive  fermentation  is  under  control,  and  it  may  then  be 
employed  regularly  four  hours  after  the  evening  meal.  The 
proper  time  to  employ  electricity  is  after  lavage,  the  cervico- 
gastric.spinogastric.and  von  Ziemssen  methods,  with  cathodal 
excitation,  low  density,  and  strong  currents,  and  with  short 
sittings,  being  preferred.  Electric  treatment  may  also  be 
given  with  advantage  one  or  two  hours  after  breakfast,  the 
action  of  the  remedy  on  the  secretion  and  on  the  movements  of 
the  stomach  being  used  to  promote  digestion  and  the  evacu- 
ation of  the  stomach.  In  addition  to  the  uses  of  water 
directed  against  the  myasthenia,  stomach  washing  must  be 
employed  against  the  retention  and  the  fermentation.  Another 
remedy,  required  by  the  thin  and  weak  abdominal  walls  and 
the  overweighted  stomach,  is  a  snugly  fitting  abdominal  ban- 
dage, to  give  mechanical  support.  All  constriction  about  the 
waist  should  be  removed.  The  mechanical  support  and  the 
removal  of  compression  are  valuable  aids  to  the  evacuation  of 
the  stomach  and  the  bowels. 

One  of  the  most  difficult  objects  to  attain  is  the  nourishment 
of  the  patient.  To  maintain  the  balance  of  nutrition  all  our 
resources,  if  necessary,  should  be  brought  to  bear;  including 
a  proper  diet,  whose  utilization  is  protected  and  aided,  and 
supplemented,  when  necessary,  by  rectal  feeding.  The  reme- 
dies which  control  fermentation  and  which  aid  the  evacuation 
of  the  stomach  contribute  to  this  end. 

The  diet  of  retention  myasthenia  should  be  nutritious,  in 


MYASTHENIA    GASTRIC  A.  375 

small  bulk,  resistant  to  fermentation,  sufficient  to  support 
nutrition,  and  capable  of  utilizationby  the  intestines.  Digestive 
compensation  is  dependent  largely  on  the  integrity  of  the 
functions  of  the  intestines,  the  retained  gastric  contents  being 
unabsorbed  and  serving  only  as  food  for  the  large  quantity  of 
germs. 

Sweets  should  be  excluded,  and  fat  (only  in  the  form  of 
fresh  butter)  should  be  given  in  moderation.  Oil  rubbings 
may  be  employed  to  furnish  part  of  the  fat  required  to  support 
nutrition.  Meats,  fish,  and  the  whites  of  eggs  form  the  staple 
articles  of  diet,  and  should  be  given  freed  from  all  indigestible 
matter  and  finely  divided.  The  meat  jellies,  resisting  fermen- 
tation and  filling  a  deficiency  created  by  the  sweets,  are  very 
valuable.  Rice  and  the  preparations  of  wheat  are  the  best 
cereals,  and  dry  toasted  bread  may  be  allowed.  Dry  meat 
powder  and  "  somatose "  are  very  concentrated  foods,  and 
where  too  little  food  is  eaten  they  may  be  introduced  into  the 
stomach  through  the  tube  at  the  end  of  the  morning  lavage. 
Fruits  of  all  kinds  should  be  excluded,  and  cases  are  hardly 
known  where  milk  agrees.  A  glass  of  water  should  be  allowed 
with  each  meal,  and  a  little  old  whisky  or  brandy  may  be 
permitted  if  the  disease  is  not  so  far  advanced  that  gastric 
absorption  is  reduced  to  zero.  Alcohol  is  absorbed  by  the 
normal  stomach,  and  promotes  also  the  absorption  of  other 
food  products. 

As  a  rule,  it  is  best  to  furnish  only  three,  or  at  most  four, 
meals  a  day.  The  frequent  administration  of  small  quantities 
of  food  robs  the  stomach  of  the  possibility  of  repose,  and  is  a 
good  way  to  make  sure  of  gradual  gastric  retention.  But  in 
a  few  cases  the  stomach  is  capable  of  evacuating  small  quan- 
tities of  fluid  food,  and  retention  may  be  avoided  by  giving 
the  nourishment  frequently  and  in  small  quantities.  This  power 
and  peculiarity  of  the  stomach  is  more  often  met  with  in  the 
beginning  of  myasthenic  retention,  and  where  the  stomach  is 
not  sensibly  enlarged.  All  the  food  should  be  given  in  a  state 
of  fine  division,  so  as  to  favor  its  evacuation  by  the  stomach 
and  its  utilization  by  the  intestines,  and  to  facilitate  thorough 
lavage. 

Since  its  recommendation  by  Kussmaul,  stomach  washing 
has  become  a  classical  remedy  in  gastric  retention.  The 
technic  of  the  procedure  has  already  been  described.  In  the 
treatment  of  myasthenic  retention  the  most  favorable  time 
for  its  employment  is  in  the  early  morning  before  any  food 
has  been  taken.  This  is  usually  sufficient  to  control  the  fer- 
mentation ;  it  protects  the  intestines,  removes  but  little  food 


376  DISEASES  OF  THE   STOMACH. 

that  is  likely  to  prove  of  nutritive  value,  and  the  stomach 
begins  the  work  of  the  day  fresh  and  clean.  The  contents  of 
the  stomach  should  be  expressed  and  the  stomach  should  be 
thoroughly  washed  out  with  warm  boiled  water,  to  which  an 
alkali  or  one  of  the  many  antiseptics  recommended  may  be 
added.  The  following  are  the  antifermentative  solutions  most 
often  used  :  Salicylic  acid  (i  :  1000),  boracic  acid  (i  :  100), 
borax  (five  per  cent.),  benzoate  or  salicylate  of  sodium  (one  per 
cent.),  permanganate  of  potash  (i  :  looo).  After  thoroughly 
washing  out  the  stomach  with  warm  boiled  water,  a  pint 
of  a  borosalicylic  solution  (acid  boracic,  oj  ;  acid  salicylic, 
grs.  XX  ;  aq.,  Oj)  should  be  allowed  to  flow  in,  be  brought 
thoroughly  in  contact  with  the  mucous  membrane  by  lower- 
ing and  raising  the  funnel  several  times,  and  should  then  be 
allowed  to  flow  out.  This  is  a  very  efficient  solution.  The 
stomach  should  be  left  empty.  In  a  few  cases,  in  order  to 
secure  sleep,  to  give  a  long  rest  to  the  stomach,  and  to  control 
obstinate  fermentation,  it  is  necessary  to  perform  lavage  in 
the  evening — as  late  as  possible  after  the  evening  meal.  The 
stomach  may  be  washed  out  thoroughly  (the  contents  being 
previously  e.xpressed)  with  a  warm  alkaline  solution,  and  5ss 
each  of  salicylate  and  bicarbonate  of  soda,  dissolved  in  a  few 
ounces  of  water,  may  be  left  in  the  stomach  during  the  night. 
This  alkaline  antifermentative  solution  readily  destroys  yeast 
and  sarcinne.  On  the  following  morning  the  intragastric 
douche  ma\'  be  employed,  using  then,  also,  the  borosalicylic 
solution.  The  excessive  fermentation  will  soon  be  controlled 
by  this  method,  a  daily  morning  lavage  being  thereafter  suffi- 
cient to  check  the  germ  growth.  Rarely,  it  may  be  neces- 
sary to  combine  with  the  lavage  functional  repose  of  the 
stomach  and  rectal  feeding  for  a  few  da\'s. 

With  some  authors  the  administration  of  antifermentative 
drugs  is  in  great  favor.  Of  these  drugs  the  following  may 
be  mentioned,  and  given  without  much  hope  of  benefiting  the 
patient:  Resorcin  resublimat.  (Merck's),  grs.  iij  to  v;  bismuth 
salicylate,  grs.  v  ;  salol,  grs.  x  ;  beta-naphthol,  grs.  iij  ;  sodium 
salicylate,  grs.  v  ;  salicin,  grs.  x  ;  creosote,  gtt.  iij ;  sodium 
benzoate,  grs.  v  ;  ichthyol,  gr.  j  ;  aq.  chloroformi,  ^ss.  These 
drugs  may  be  prescribed  in  the  above  doses,  three  times  a 
day  after  meals,  in  various  combinations. 

The  treatment  of  myasthenic  retention  by  the  systematic 
use  of  these  remedies  often  gives  relief,  and  may  produce  a 
complete  cure.  But  the  result  is  not  always  so  satisfactory, 
and,  even  at  the  price  of  their  continued  daily  employment, 
the  patient  may  be  insufficiently  nourished  and  unrelieved  of 


MYASTHENIA    GASTRICA.  377 

his  sufferings.     As  a  last  resource,  the  aid  of  a  surgeon  may 
be  invoked. 

The  operation  of  Bircher  is  yet  in  its  infancy,  but  where 
the  motor  power  is  not  completely  destroyed  it  would  seem 
to  be  worthy  of  further  experimentation.  The  object  of  the 
operation  is  the  diminution  of  the  size  of  the  stomach,  the 
elevation  of  the  greater  curvature  by  infolding  the  anterior 
wall  in  the  line  of  the  long  axis  of  the  stomach,  and  the  union 
of  the  peritoneal  edges  of  the  infolded  part  along  the  lesser 
curvature.  From  this  line  of  union  hangs  the  anterior  wall, 
the  stomach  being  unopened  by  the  operation.  Prof  Weir 
also  employed  the  same  method  to  reduce  the  size  of  a 
"  dilated"  stomach  in  a  patient  suffering  from  retention,  some 
time  after  the  performance  of  gastro-enterostomy,  making 
several  folds  in  the  direction  of  the  long  axis  of  the  stomach. 
The  preferable  operation  is  gastro-enterostomy. 


SECTION  V. 
THE  ANATOMICAL  DISEASES  OF  THE  STOMACH. 

CH  AFTER   1. 
GASTRITIS. 

Inflammation  of  the  internal  glandular  lining  membrane 
of  the  stomach  may  be  acute  or  chronic. 


ACUTE  GASTRITIS. 

Acute  gastritis  presents  three  distinct  clinical  and  patho- 
logical forms,  each  possessing  a  characteristic  genesis  and  evo- 
lution, and  demanding  special  treatment.  These  three  forms 
of  acute  gastritis  are  :  (i)  Simple  gastritis  ;  (2)  mycotic  gas- 
tritis ;  (3)  toxic  gastritis. 

Acute  simple  gastritis  is  an  afebrile  inflammation  of  the 
mucous  membrane  of  the  stomach  excited  by  neither  micro- 
organisms nor  poisons.  A  gastritis  excited  by  germs  develop- 
ing in  the  cavity  of  the  stomach  or  in  its  walls  is  mycotic. 
Toxic  gastritis  is  an  inflammation  of  the  internal  layer  of  the 
stomach,  excited  by  the  accidental  or  intentional  administra- 
tion of  a  poison.  Many  of  these  poisons  are  included  among 
the  articles  of  the  materia  medica. 


I.     ACUTE  SIMPLE  GASTRITIS. 

Acute  simple  gastritis  is  a  very  frequent  disease  ;  it  may 
be  very  mild  and  transient,  and  may  pass  away  after  a  few 
meals  have  been  digested  with  difficulty  and  discomfort;  or  it 
may  be  expressed  by  signs  of  greater  irritation,  such  as  nausea, 
vomiting,  and  depression.  It  is  often  described  as  indigestion 
or  as  acute  gastric  catarrh. 

Etiology. — Two  factors  play  a  more  or  less  important  part 
in  its  causation  :  bad  alimentation  and  a  diminished  resistance 

378 


GASTRITIS.  379 

to  disturbing  influences  on  the  part  of  the  organ.  One  or 
both  of  these  morbific  causes  may  be  active,  the  inflam- 
mation being  the  result  of  excessive  irritation  or  of  a  morbid 
sensibiHty  of  the  mucous  membrane  to  even  normal  excita- 
tion. 

The  soil  may  be  prepared  for  the  development  of  the  disease 
in  many  ways,  all  of  which  act  through  a  derangement  of  one 
or  more  of  the  physiological  factors  of  digestion.  The  influ- 
ence of  heredity  has  been  frequently  asserted  without  con- 
clusive reasons  ;  common  family  dietetic  faults  constitute  a 
stronger  predisposition.  "  I  inherit  my  bad  stomach,  and  my 
family  as  far  back  as  I  can  go  has  been  dyspeptic."  There 
may  be  some  consolation  in  posing  as  the  victim  of  uncon- 
trollable circumstances,  but  a  man's  stomach,  as  regards  its 
primary  diseases,  is  what  he  has  made  it.  We  readily  admit, 
however,  the  inheritance,  and  also  the  influence  of  the  catarrhal 
and  the  uric  acid  diatheses.  Exposure  to  excessive  heat  or 
cold  during  the  period  of  digestion,  mental  or  physical  fatigue, 
intense  moral  anxiety  or  depression,  etc.,  may  render  the 
stomach  relatively  incapable,  and  may  create  the  morbid  op- 
portunity. 

The  inflammation  may  often  be  attributed  to  very  palpable 
errors  of  diet — the  food  and  drinks,  on  account  of  their  quan- 
tity or  quality,  or  their  delayed  evacuation,  producing  exces- 
sive stimulation.  The  disease  begins  frequently  after  a  rela- 
tively rich  and  rapidly  eaten  meal.  The  chemical  irritants 
may  be  proper  to  the  food  or  drinks,  or  may  be  developed  in 
the  uneaten  food  by  fermentation,  or  added  by  the  cook  with 
an  excessive  desire  to  please  the  palate.  Or  the  excitant  may 
be  thermal,  the  food  or  drinks  being  too  hot  or  too  cold.  The 
most  common  cause  is  the  irritant  quality  of  the  diet — 
mechanical,  chemical,  and  thermal.  Alcohol  may  often  be 
incriminated,  and  cold  beer  seldom  fails  to  produce  the  disease. 
Many  articles  of  the  materia  medica  in  therapeutic  doses  are 
capable  of  producing  the  inflammation — arsenic,  the  iodids, 
the  bromids  in  strong  solution,  salines,  and  excessive  quanti- 
ties of  common  salt. 

Pathological  Anatomy. — Acute  simple  gastritis  not  being 
a  fatal  disease,  an  opportunity  to  study  its  pathological  an- 
atomy is  very  rare.  The  inflammation  is  superficial,  and  the 
signs  are  soon  effaced  by  postmortem  changes.  The  circula- 
tion phenomena  may  be  very  different  after  death  from  those 
present  during  life,  and  nothingmay  be  left  except  ecchymoses 
to  recall  the  intense,  active  hyperemia.  But  observations 
through  a  gastric  fistula,  experiments  on  animals,  and  a  few 


380  DISEASES  OF  THE  STOMACH. 

cases  examined  soon  after  death  due  to  intercurrent  accidents, 
enable  us  to  describe  the  morbid  anatomy. 

The  lining  membrane  is  covered  with  a  layer  of  tough 
mucus,  which  may  be  here  and  there  tinged  a  rose  color. 
The  mucous  membrane  is  red  in  patches,  studded  here  and 
there  with  punctate  superficial  hemorrhages,  and  swollen. 
Beaumont  described  small  vesicles,  separated  by  patches  of 
deep  congestion,  in  the  stomach  of  Ale.xis  St.  Martin  during 
an  attack  of  acute  gastritis.  These  appearances  are  most  pro- 
nounced in  the  region  of  the  pylorus,  and  spread  to  a  variable 
extent  over  the  internal  surface.  The  surface  cells  are  swollen 
and  distended  with  mucus,  desquamated,  and  mixed  with  leu- 
kocytes in  the  mucus  covering  the  surface.  The  chief  cells 
are  granular,  stain  deeply,  are  often  shriveled,  and  may  be 
seen  lying  free  in  the  lumen  of  the  glands,  which  may  be 
filled  with  degenerate  granular  matter  and  a  fluid  resembling 
mucus.  The  border  cells  appear  unchanged.  The  capillaries 
are  enlarged  and  distended,  and  there  is  small-cell  infiltration, 
particularly  along  the  venous  radicles,  and  extending  even  into 
the  submucosa.  After  the  acute  inflammation  has  lasted  a 
few  days,  the  infiltration  of  the  interglandular  spaces  with 
small  lymphoid  or  embryonic  cells  may  be  greater ;  and  the 
infiltration  may  be  diffuse,  or  it  may  be  limited  to  the  super- 
ficial or  to  the  deeper  parts  of  the  mucous  membrane ;  or  it 
may  occur  in  small,  sharply  limited  nodules,  very  rich  in  small 
cells  ;  or  in  larger  patches  which  are  gradually  lost  in  the 
adjacent  healthy  parts.  These  infiltrating  embryonic  cells 
stain  lightly,  and  contain  a  very  large  nucleus.  Mi.xed  with 
these  small  cells  is  a  large  or  small  number  of  wandering 
leukocytes,  accordingly  as  the  inflammation  is  more  or  less 
intense.  The  endothelium  of  the  lymphatics  may  be  cloudy, 
swollen,  and  undergoing  desquamation.  It  is  more  than 
probable  that  the  histological  changes  may  be  confined  to  the 
surface  cells  in  very  mild  cases,  and  the  exudation  and  the 
desquamation  may  be  accompanied  simply  by  active  hyper- 
emia. In  some  cases  the  inflammation  may  be  almost  exclu- 
sively parenchymatous,  when  the  most  marked  lesion  is 
degeneration  of  the  chief  cells.  In  other  cases  the  inflam- 
mation may  be  interstitial  and  characterized  by  infiltration 
with  embryonic  cells  and  leukocytes.  Rarely,  the  inflamma- 
tion may  be  diffuse. 

Clinical  Description. — The  disease  begins  during  the  period 
of  digestion,  without  chill,  pain,  or  fever.  The  patient  feels 
dull,  uncomfortable,  weak,  and  indisposed  to  work.  The 
stomach  is  heavy  and   full,  the  respiration  shallow,  and  the 


GASTRITIS.  381 

pulse  may  be  large  and  compressible  or  small  and  slightly 
increased  in  frequency.  There  is  slight  nausea,  often  a  dull 
frontal  headache ;  and  there  may  be  ringing  in  the  ears,  or 
vertigo,  increased  by  movement  or  by  the  upright  position. 
The  face  is  pale,  the  expression  haggard,  and  the  extremities 
cold.  The  stomach  may  empty  its  contents  into  the  intestines, 
and  these  symptoms  subside  ;  or  the  nausea  may  increase  and 
lead  to  vomiting,  which  the  patient  may  instinctively  excite. 
During  the  period  of  digestive  rest  there  is  physical  and  men- 
tal depression,  the  appetite  is  lost,  and  there  may  be  disgust 
for  the  usual  food,  and  the  patient  may  long  for  sour  or  spicy 
articles.  The  mouth  is  sticky,  and  the  large  white  tongue 
possesses  a  brownish,  thick  coating  of  mucus,  bacteria,  and 
epithelium  over  its  base,  while  the  reddened  edges  bear  the 
imprint  of  the  teeth.  The  sleep  is  broken,  the  bowels  con- 
stipated, or  there  may  be  one  or  two  diarrheal  movements 
containing  mucus  and  producing  burning  and  tenesmus. 
The  urine  is  small  in  quantity  and  deposits  urates  on  stand- 
ing. The  trouble  may  subside  in  a  few  days  under  the  influ- 
ence of  rest  and  a  small  quantity  of  non-irritating  food  ;  or 
the  disease,  under  improper  treatment,  may  become  compli- 
cated with  gastric  fermentation  and  be  transformed  into  my- 
cotic gastritis ;  or  the  subjective  digestive  symptoms  may 
recur  with  diminishing  intensity  until  recovery  is  complete. 

Throughout  the  course  of  the  disease  there  is  no  gastric 
pain,  but  diffuse  tenderness,  and  no  fever,  except  a  slight  pos- 
sible increase  of  temperature  over  the  stomach  during  the 
period  of  digestion.  But  children  may  show  a  rise  of  about 
one  degree  in  the  general  temperature. 

The  vomit  is  copious  and  consists  of  undigested  food,  par- 
ticularly meat,  mixed  with  mucus;  it  may  contain  no  free 
HCl,  and  it  may  be  neutral  or  alkaline  in  reaction,  or  slightly 
acid  on  account  of  the  hardly  noticeable  fermentation.  The 
organic  acid  is  usually  butyric.  Or  the  vomit  may  be  exces- 
sively acid  (H  +  C),  and  contain  bile  and  mucus  stained  with 
fresh  blood.  The  special  secretion  of  the  stomach  may  be 
suppressed  on  account  of  the  congestion  and  the  degeneration 
of  the  chief  cells.  The  excessive  secretion  of  mucus  and  the 
inflammatory  exudation  diminish  the  quantity  of  free  HCl, 
if  any  is  secreted.  Or  secretion  may  be  active  as  an  expres- 
sion of  the  irritation,  the  inflammation  being  then  probably 
superficial  or  interstitial. 

Diagnosis. — The  beginning  during  the  period  of  digestion, 
the  short  duration  without  fever  or  noteworthy  pain,  the 
subsidence    of   the    symptoms    after   the    evacuation    of  the 


382  DISEASES  OE  THE  STOMACH. 

Stomach  or  the  digestive  tube,  and  the  characteristics  of  the 
vomit, — leave  little  doubt  as  to  the  nature  of  the  disease. 

Treatment. — The  treatment  of  simple  acute  gastritis  is 
best  conducted  without  the  use  of  drugs. 

If  the  patient  is  seen  before  the  stomach  has  been  emptied 
by  vomiting,  a  glass  of  water  at  90°  F.  may  be  administered 
and  vomiting  excited  by  the  finger  in  the  pharynx.  It  is 
seldom  necessary  or  advisable  to  use  an  emetic  or  lavage. 
The  stomach,  once  empty,  is  left  completely  at  rest  for  several 
hours,  a  little  barley  water,  lemonade,  or  egg  water,  being 
used  to  quench  thirst. 

For  twenty-four  to  thirty-six  hours  the  stomach  should  be 
given  functional  rest.  At  the  end  of  this  time  a  little  thor- 
oughly cooked  cereal,  or  meat  juice,  or  preparation  of  milk 
may  be  ordered;  then  the  more  digestible  finely-divided 
meats,  a  little  dry  toast  or  cracker,  or  crust  of  roll.  At  the 
end  of  two  or  three  days  the  patient  can  be  given  an  ordinary 
mixed  diet  composed  of  the  foods  which  have  little  physio- 
logical action  on  the  stomach.  To  the  cereals  and  meats, 
butter,  vegetables,  and,  last  of  all,  sweets,  may  be  added  in 
relation  to  the  rapidity  of  recovery  and  the  return  of  the 
functional  power  of  the  stomach,  which,  after  the  first  day  or 
two,  may  be  improved  by  small  doses  of  strychnin  or  of  nux 
vomica. 

Recovery  may  be  hastened  and  the  nausea  controlled  by 
the  cold  compress,  applied  according  to  the  method  of  Win- 
ternitz. 

The  constipation  should  be  relieved  by  an  enema  of  warm 
water,  to  which  a  teaspoonful  of  glycerin  may  be  added.  If 
the  irritant  has  passed  into  the  intestines,  a  dose  of  calomel 
may  be  given  with  benefit.  The  evacuation  of  the  stomach, 
the  compress,  the  functional  rest,  the  protection  of  the  stomach 
against  irritation,  and  the  relief  of  the  constipation  by  injec- 
tions are  the  remedies  most  conducive  to  rapid  and  complete 
recovery. 

II.  MYCOTIC  GASTRITIS. 

Mycotic  gastritis  may  exist  in  three  forms.  In  one  the 
characteristic  sign  is  acute  gastric  fermentation,  the  result  of 
which  is  an  inflammation  of  the  mucous  membrane.  Acute 
gastritis  may  also  be  produced  by  eating  food  which  has 
undergone  putrefaction.  The  attacks  begin  like  acute  poison- 
ing, with  headache,  vertigo,  nausea,  vomiting,  dyspnea,  col- 
lapse, delirium,  and  with  other  symptoms  which  vary  according 


GASTRITIS.  383 

to  the  dose  and  the  nature  of  the  putrefaction  poisons.  But 
these  cases  are  not  cases  of  gastric  putrefaction,  which  never 
occurs  except  as  a  result  of  gastric  retention.  Putrefaction 
poisons  may  produce,  however,  no  inflammation  of  the  mucous 
membrane  of  the  stomach,  acting  in  this  respect  like  alkaloid 
poisons.  These  cases  of  acute  food  poisoning  are  not  pro- 
duced by  acute  gastric  putrefaction,  and  do  not  constitute  a 
distinct  clinical  form  of  gastritis,  like  the  inflammation  excited 
by  acute  gastric  fermentation.  Gastritis  may  also  be  excited 
by  bacteriological  products  brought  to  the  stomach  by  the 
blood.  The  stomach  may  eliminate  the  poison,  and  the 
anatomical  changes  may  begin  on  the  surface,  as  in  simple 
acute  gastritis  ;  or  the  lesions  may  develop  from  the  capil- 
laries and  involve  secondarily  the  tissues  fed  by  them.  Fur- 
thermore, mycotic  gastritis  may  be  caused,  not  by  germs 
developing  in  the  contents  of  the  stomach  nor  by  bacterial 
products  brought  to  it  by  the  blood,  but  by  bacteria  which 
invade  and  inflame  its  proper  tissues.  This  latter  form  is 
infectious.  Consequently  the  two  varieties  of  primary  acute 
mycotic  gastritis  are  :  {a)  The  fermentation  form  ;  and  (^)  the 
infectious  forms. 

In  regard  to  the  fermentation  form,  it  may  be  contended 
that  the  fermentation  is  the  distinctive  and  predominant 
characteristic,  and  that  the  trouble  should  be  properly  named 
"  acute  gastric  fermentation."  The  force  of  this  contention  may 
be  readily  admitted;  but  the  fermentation  is  the  expression 
of  the  conditions  which  permit  it — a  mere  sign.  In  the 
genesis  of  the  gastritis  it  forms  the  connecting  link,  and  may 
serve  to  define  it.  The  morbid  evolution  has  passed  into 
the  anatomical  stage  which  is  accurately  described  by  acute 
cfastritis  due  to  fermentation. 


(A)  The  Fermentation  form  of  Mycotic  Gastritis. 

Etiology. — Gastritis  due  to  fermentation  is  more  frequent  in 
infancy,  on  account  of  the  peculiar  and  exclusive  alimentation, 
than  at  any  other  period  of  life.  The  two  extremes  of  life 
agree  in  this  respect — that  both  are  more  liable  to  the  disease 
than  is  the  middle  period.  In  old  age  the  stomach  has  been 
made  slow  in  action  and  incapable,  or  in  the  course  of  nature 
has  grown  to  be  so. 

Thus  we  have  the  two  conditions  of  the  active  fermentation 
in  the  stomach  which  is  the  exciting  cause  and  the  distinctive 
characteristic  of  the  gastritis — a  diet  forming  a  good  culture 
soil  richly  infested  with  germs,  and  stagnation  due  to  acute 


384  DISEASES  OF  THE  STOMACH. 

motor  insufficiency  of  the  stomach.  The  disease  is  most  fre- 
quent in  summer,  when  the  germs  of  fermentation  are  most 
plentiful  and  virulent,  digestion  torpid,  and  the  stomach  often 
overloaded  with  drinks. 

Pathological  Anatomy. — The  anatomical  changes  do  not 
differ  materially  from  those  of  acute  simple  gastritis,  but  may 
be  more  intense  and  diff"use,  in  keeping  with  their  production 
by  irritants  in  solution.  Consequently  the  surface  cylindrical 
epithelium  degenerates  and  desquamates  to  a  greater  extent 
than  in  simple  acute  gastritis,  while  the  changes  in  the  glands 
and  in  the  interglandular  tissue  are  variable. 

Clinical  Description. — This  form  of  acute  mycotic  gastritis 
maybe  febrile  or  afebrile.  Where  the  disease  runs  its  course 
without  fever  it  may  present  two  clinical  types — a  mild  and 
a  severe  form. 

The  mild  form  may  begin  suddenly  during  the  night  or 
may  be  preceded  for  a  day  or  two  by  slight  headache,  belch- 
ing, and  regurgitation  of  a  fluid  which  is  sometimes  without 
pronounced  taste,  is  sometimes  sour,  and  sometimes  has  an 
odor  of  acetic  or  butyric  acid.  These  premonitory  symptoms 
occur  during  the  period  of  digestion,  and  are  made  worse  by 
fermentable  food.  Then  comes  the  attack,  which  usually 
occurs  at  night  or  three  or  four  hours  after  the  chief  meal. 
The  stomach  is  distended,  contains  an  excess  of  gas,  is  tender 
on  pressure,  but  in  the  mild  form  there  is  rarely  distinct  pain. 
Nausea  is  common,  with  frontal  headache,  which  may  be 
severe,  and  no  relief  is  obtained  until  the  stomach  is  evacuated. 
The  vomit  is  like  that  of  simple  gastritis  plus  fermentation, 
and  is  more  fluid  on  account  of  the  more  active  secretion. 
The  symptoms  may  subside  with  the  vomiting  or  the  intes- 
tines may  have  received  a  portion  of  the  fermenting  chyme  to 
eliminate  by  a  few  diarrheal  movements.  Convalescence  may 
be  complete  in  four  or  five  days  under  proper  treatment,  or 
may  be  prolonged  by  a  persistence  of  the  conditions  which 
led  up  to  the  attack. 

In  the  severe  form  the  local  symptoms  are  more  intense 
and  the  constitutional  symptoms  are  more  pronounced.  But 
the  severe  form  is  not  simply  the  mild  form  magnified.  In 
addition  to  the  fermentation  and  the  gastritis  excited  by  it, 
there  is  also  auto-into.xication,  and  the  intestines  and  the  liver 
become  secondarily  involved. 

The  severe  form  may  be  preceded  by  the  mild  form,  or 
may  develop  as  a  sequel  of  acute  simple  gastritis,  or,  more  fre- 
quently, suddenly,  during  the  digestive  period,  with  premon- 
itory symptoms.    There  is  commonly  a  slight  chill,  with  little 


GASTRITIS.  385 

or  no  fever,  intense  headache,  nausea,  dull  or  severe  pain,  and 
epigastric  tenderness  proportionate  to  pressure.  These  symp- 
toms are  increased  by  additional  food  or  drinks.  The  stomach 
is  distended,  the  respiration  shallow,  the  pulse  small  and  fre- 
quent, and  often  hard,  and  the  patient  is  agitated,  anxious,  and 
prostrated.  The  appetite  is  completely  lost ;  thirst  is  often 
intense.  The  vomit  consists  of  food,  of  secretion,  of  exuda- 
tion, and  of  the  products  of  fermentation.  The  attack  is  not 
cut  short  by  vomiting,  but  the  gastric  symptoms  are  tempo- 
rarily relieved.  The  vomiting  may  be  frequently  repeated, 
and  may  be  accompanied  by  severe  and  painful  retching  and 
slight  capillary  hemorrhage.  The  stomach  evacuates  part  of 
its  contents  into  the  duodenum,  and  intestinal  irritation  and 
fermentation  are  added,  leading  to  several  large  fermenting 
stools,  which  may  smell  musty.  The  liver  is  enlarged  and 
congested,  the  spleen  is  normal  in  size,  and  the  slight  icterus, 
which  is  not  rare,  is  probably  the  result  of  the  duodenitis 
extending  into  or  obstructing  the  common  duct,  or  producing 
spasm  of  its  sphincter.  The  severe  form  may  last  a  few  days 
or  one  or  two  weeks,  in  keeping  with  the  extent  and  the 
intensity  of  the  excited  inflammation  ;  or  it  becomes  not 
infrequently  subacute  and  chronic. 

The  disease  begins  with  active  fermentation  in  the  stomach, 
producing  irritation  and  gastritis,  and,  extending  to  the  in- 
testines, becomes  associated  with  intestinal  irritation  or  with 
enteritis. 

Diagnosis. — The  diagnosis  of  the  fermentation  form  of  my- 
cotic gastritis  is  dependent  on  the  grouping  of  the  subjective 
and  the  objective  signs  as  detailed  in  the  clinical  history,  and 
on  the  detection  in  the  gastric  contents  of  the  signs  of  acute 
inflammation  and  of  active  fermentation.  In  addition  to  the 
chemical  and  the  microscopical  examination  of  the  vomit,  the 
fermentation  tube  test  should  be  made. 

The  differential  diagnosis  may  present  some  difficulties  ; 
and  simple  acute  gastritis,  and  the  gastric  crises  announcing 
the  commencement,  or  occurring  in  the  course  of  other  dis- 
eases, may  be  confounded  with  it.  But  active  gastric  fermen- 
tation developing  proportionately  with  the  evolution  of  the 
symptoms  is  a  definitive  sign. 

Prognosis. — The  prognosis  of  the  mild  form  is  good. 
The  severe  form  may  do  lasting  injury,  and  leave  chronic 
gastritis  or  enteritis  as  a  legacy.  In  very  old  or  weak  patients 
and  in  advanced  diseases  of  other  organs  the  prostration 
may  be  fatal.  It  is  not  the  disease  itself,  but  the  disease 
aided  by  its  associations,  which  kills. 
25 


386  DISEASES  OF  THE  STOMACH. 

Treatment. — The  indications  as  to  the  plan  of  treatment 
are  three:  (i)  Control  the  fermentation;  (2)  reHeve  the 
gross  symptoms  ;  (3)  treat  tlie  lesion. 

To  control  the  fermentation  it  is  absolutely  necessary  that 
the  stomach  shall  be  completely  emptied.  This  may  be 
imperfectly  done  by  vomiting  and  by  copious  drafts  of 
warm  water — the  vomiting  being  excited  by  the  disease  or 
artificially.  But  where  it  can  be  used,  stomach  washing  is 
certainly  the  most  efficient  method  of  cleansing  the  stomach. 
In  the  severe  form  the.  intestines  are  also  infected,  and  there 
may  be  auto-intoxication.  A  dose  of  Epsom  salts,  or  of  the 
effervescing  citrate  of  magnesia,  will  remove  both  these  com- 
plications. Afterward,  the  large  bowel  should  be  washed  out. 
The  digestive  tube  being  clean,  there  may  be  given  to  quiet 
the  irritation  a  large  dose  of  bismuth  (j^  to  I  dram),  with 
which  maybe  combined  an  anodyne — the  deodorized  tincture 
of  opium  or  the  phosphate  of  codein.  The  stomach  should 
be  kept  free  from  food,  which  would  serve  as  a  germ  culture 
soil,  for  from  twelve  to  twenty-four  hours. 

To  relieve  the  gross  symptoms — the  nausea  and  vomiting, 
pain  and  prostration — much  will  already  have  been  done  by 
cleansing  the  digestive  tube  and  by  the  administration  of  the 
bismuth  and  the  opiate.  But  pain  may  require  the  earlier 
hypodermic  administration  of  morphin,  and,  if  the  prostration 
be  v^ery  great,  camphorated  oil  (i  gr.  in  10  minims  of  oil  of 
sweet  almonds)  or  strychnin  should  be  given  hypodermi- 
cally.  After  the  copious  vomiting,  dry  champagne  may  be 
ordered  with  benefit. 

The  treatment  of  the  lesion  consists  in  the  use  of  the  same 
remedies  as  in  acute  simple  gastritis — functional  rest  and 
favoring  of  the  stomach,  rest  in  bed,  the  compress,  and  the 
administration  of  strychnin  as  the  reparative  process  ad- 
vances. 

(B)     INFECTIOUS  FORMS. 

Acute  gastritis  may  be  produced  by  pathogenic  germs 
which  grow  on  the  surface  of  the  mucosa,  or  which  develop 
in  the  structures  that  compose  the  gastric  wall.  Growths 
of  favus,  of  thrush,  and  of  the  larvae  of  insects  on  the  mu- 
cous membrane  of  the  stomach  are  curiosities  of  medicine. 
Trichinosis  and  actinomycosis  may  affect  the  stomach.  Acute 
gastritis,  with  sometimes  pseudomembranous  formation,  may 
occur  in  scarlatina,  variola,  typhus,  pyemia,  and  septicemia. 
The  bacillus  of  anthrax,  the  streptococcus  erysipelatosus,  and 
the   bacillus   of  influenza  may  produce  their  peculiar  tissue 


GASTRITIS.  387 

alterations  in  the  gastric  mucosa.  Diphtheric  gastritis  is  very- 
infrequent,  and  is  always  secondary  to  diphtheria  of  the 
upper  air-passages.  But  only  two  forms  of  infectious  gastritis 
are  of  practical  interest :  purulent  gastritis  and  gastric  fever. 


(l)     PURULENT  GASTRITIS. 

Gastritis  accompanied  by  diffuse  or  circumscribed  suppura- 
tion, due  to  the  invasion  of  the  gastric  wall  by  the  pus- 
forming  bacteria,  is  a  rare  disease.  In  going  through  the 
literature  of  the  subject,  only  65  well-authenticated  cases 
have  been  found. 

Etiology. — The  disease  is  due  to  the  development  within 
the  gastric  wall  of  the  pus-forming  bacteria.  The  majority  of 
the  cases  have  occurred  as  secondary  infections — in  pyemia, 
puerperal  fever,  gastric  ulcer,  gastric  carcinoma,  purulent 
meningitis,  variola,  and  scarlatina.  In  other  cases  ordinary 
lesions  of  the  stomach,  such  as  traumatism  and  gastritis,  have 
afforded  the  opportunity  for  bacterial  invasion.  About 
five-sixths  of  the  reported  cases  occurred  in  men. 

Pathological  Anatomy — The  pathological  anatomy  is  that 
of  purulent  cellulitis,  the  pus  being  diffused  or  collected  in 
the  submucosa,  particularly  about  the  pylorus.  The  process 
extends  along  the  lymphatics  and  the  blood-vessels  to  the 
peritoneum  and  to  the  mucous  membrane.  The  gastric  wall 
is  swollen  four  or  five  times  thicker  than  normal,  and  is  infil- 
trated with  inflammatory  products.  The  pus  may  be  diffused, 
or  may  be  collected  in  a  single  abscess,  or  in  multiple  ab- 
scesses. As  a  rule,  there  is  only  one  abscess,  which  may  vary 
in  size,  and  is  usually  situated  near  the  pylorus.  The  involved 
peritoneum  may  be  covered  with  a  thick,  fibrinous  false 
membrane,  or  adhesions  may  be  formed  with  adjacent  parts, 
or  the  peritoneum  may  be  but  slightly  or  not  at  all  inflamed. 
The  mucous  membrane  may  be  but  little  changed,  or  may  be 
intensely  red,  hemorrhagic,  ulcerated,  or  perforated  by  many 
small  openings,  extending  through  the  interglandular  con- 
nective tissue  down  to  the  pus-infiltrated  submucosa.  On 
pressure,  pus  oozes  through  these  openings  as  from  a  satu- 
rated sponge.  The  mucous  membrane  may  be  deprived  of 
its  blood  supply,  and  the  slough,  falling  away,  may  leave  large 
or  small  ulcers.  The  interglandular  tissue  is  infiltrated  with 
embryonic  cells  and  wandering  leukocytes.  There  may  be, 
rarely,  thrombosis  of  the  gastric,  hepatic,  and  pulmonary 
veins.  The  muscular  layer  may  be  but  little  involved,  but 
the  connective  tissue  is  infiltrated  with  pus,  the  bundles  of 


388  DISEASES  OF  THE   STOMACH. 

fibers  are  separated,  and  the  muscular  fiber  is  degenerated  or 
disintegrated.  The  abscess  may  open  into  tlie  stomach,  or 
the  peritoneal  cavity,  or  the  pleural  cavity;  or  may  burrow 
through  adhesions  into  adjacent  organs. 

Clinical  Description. — The  disease  usually  begins  suddenly, 
with  a  se\ere  chill,  though  in  some  of  the  cases  there  have 
been,  for  two  or  three  days  preceding  the  commencement, 
symptoms  of  digestive  disorder  or  symptoms  of  the  primary 
disease  of  which  the  purulent  gastritis  is  a  secondary  infec- 
tion. The  chill  is  accompanied  by  high  fever,  which  is  usu- 
ally remittent,  ranging  from  102°  to  105°  F. ;  and  the  rigor 
may  be  several  times  repeated  during  the  evolution  of  the 
disease.  There  are  great  prostration  and  extremely  severe 
epigastric  pains,  which  may  not  be  increased  by  pressure;  and 
the  stomach  may  be  retracted  in  the  commencement,  but  soon 
relaxes,  and  is  distended  with  gas.  There  is  nausea,  repeated 
vomiting,  pinched  countenance,  prostration,  and  the  symptom- 
group  may  suggest  acute  poisoning.  Sooner  or  later  peri- 
tonitis develops  and  adds  its  local  and  general  signs  to  those 
given  by  the  intense  cellulitis.  The  peritonitis  may  remain 
localized  or  may  become  general,  and  in  the  pyemic  cases 
the  pericardium  and  the  pleura  may  also  be  affected.  The 
brutal  beginning  is  sometimes  followed  by  a  short  period  of 
calm,  after  which  the  symptoms  become  continuous  or  remit- 
tent, and  usually  subside  again  before  the  fatal  termination  in 
collapse  or  in  coma.  Vomiting  may  not  appear  until  the  second 
day;  it  becomes  frequent,  and  finally  diminishing  in  frequency, 
subsides  during  the  calm  preceding  death.  The  vomit  con- 
sists of  undigested  food,  mucus,  inflammatory  products,  blood, 
and  bile,  but  little  or  no  pus,  except  toward  the  end,  when 
the  abscess  may  have  opened  into  the  stomach.  The  bowels 
may  be  obstinately  constipated,  but  diarrhea  is  more  common. 
Where  circumscribed,  the  abscess  may  present  a  palpable 
tumor,  which  is  usually  tender  on  pressure.  In  the  circum- 
scribed form  the  pain  and  fever  may  subside  for  a  few  days 
when  the  tumor  appears,  to  be  followed  a  few  days  later  by 
hectic  fever  and  the  signs  of  peritonitis  or  of  perforation  into 
the  stomach  or  into  some  other  cavity. 

The  general  symptoms  are  even  more  intense  than  the  local 
signs — extreme  prostration,  anxious  and  pinched  countenance, 
frequent,  small,  irregular  pulse,  delirium  with  suicidal  im- 
pulses.    Tetany  may  also  develop. 

The  duration  of  the  disease  varies  from  three  or  four  days 
to  as  many  weeks.  Where  the  suppuration  is  circumscribed, 
the  local  and  the  general  symptoms  are  less  intense,  the  fever 


GASTRITIS.  389 

becomes  ultimately  hectic,  and  the  duration  is  much  longer 
than  in  the  violent,  rapid,  and  diffuse  form.  The  average 
duration  is  about  one  week. 

The  disease  ends  fatally  in  95  per  cent,  of  the  cases.  That 
complete  recovery  is  possible  has  been  demonstrated  by 
anatomical  preparations  (Dittrich,  Deininger). 

Diagnosis. — The  disease  has  no  characteristic  sign  ;  the 
evolution  and  the  combination  of  symptoms  are  not  distinc- 
tive. The  diagnoses  of  intestinal  obstruction,  of  peritonitis, 
of  abscess  formation  in  other  parts  of  the  abdomen,  have  been 
made.  Epigastric  resistance  to  palpation  or  a  tumor  which 
becomes  less  and  disappears  after  the  vomiting  of  pus  may 
be  supposed  to  be  characteristic ;  but  this  combination  of 
signs  is  rare,  and  might  be  due  to  an  abscess  which  had  bur- 
rowed and  opened  into  the  stomach.  Corrosive  poisoning  is 
easily  excluded  by  the  absence  of  the  distinctive  effects  of 
such  poisons  on  the  mouth  and  throat. 

The  development  of  the  symptoms  in  the  course  of  one  of 
the  infectious  diseases  which  it  sometimes  complicates  may 
create  a  suspicion.  It  may  be  confounded  with  acute  pan- 
creatitis or  pancreatic  abscess,  with  perigastritis  developing 
in  the  course  of  perforating  ulcer  of  the  stomach,  with  hep- 
atic abscess,  and  with  purulent  cholelithiasis. 

Treatment. — The  treatment  is  purely  symptomatic  so  far 
as  the  medical  management  is  concerned.  Where  the  disease 
is  suspected  and  attributable  to  pus  formation  and  to  local 
peritonitis,  an  exploratory  laparotomy  is  indicated.  Surgical 
treatment  might  be  successful  where  the  pus  is  collected  in 
abscesses,  and  a  tumor,  developing  with  the  symptoms  of 
acute  purulent  inflammation,  should  be  explored  with  a 
needle,  with  a  view  to  operative  intervention. 

The  disease  usually  goes  undiagnosed  before  death,  and 
the  treatment  has  been  that  of  the  disease  for  which  it  was 
mistaken.  Functional  rest,  opium  to  relieve  pain,  control  of 
the  excessive  fever,  stimulants — summarize  the  symptomatic 
treatment.     Some  recommend  quinin. 


(2)  GASTRIC  FEVER. 
The  existence  of  this  form  of  infectious  gastritis  is  denied 
by  some  authors,  who  do  not  admit  that  the  disease  is  specific, 
but  contend  that  the  cases  reported  as  such  are  either  food 
intoxications,  severe  forms  of  common  gastritis,  or  abortive 
attacks  of  well-known  infectious  diseases,  such  as  typhoid 
fever  and  cholera. 


39©  DISEASES  OF   THE   STOMACH. 

While  the  specific  nature  of  the  disease  avvaits.the  discovery 
of  its  pathogenic  germ,  clinically  the  gastritis  is  neither  simple, 
nor  fermentative,  nor  toxic;  but  in  its  patholog\- and  evolution 
is  distinct,  and  analogous  to  the  bacterial  infections.  It  occurs 
in  persons  who  have  already  been  affected  with  typhoid  fever, 
from  which  it  is  clinically  clearly  distinct.  The  fever  is  con- 
tinuous, the  spleen  is  not  palpable,  and  the  course  is  unin- 
fluenced by  quinin,  the  administration  of  which  increases 
the  gastric  symptoms — which  is  not  the  case  where  the  Plas- 
modium malariae  exists  in  the  blood.  It  bears  a  close  resem- 
blance to  the  gastric  form  of  influenza,  but  in  our  experience 
usually  occurs  isolated  in  families  and  is  not  contagious.  The 
disease  is  more  frequent  in  spring  and  in  autumn,  and  occurs 
more  often  in  the  middle  period  of  life  than  in  infancy,  child- 
hood, and  old  age.  It  occurs  isolated,  and  endemics  have 
been  reported. 

Clinical  Description. — The  beginning  is  like  that  of  most 
infectious  diseases  of  mild  type — general  discomfort,  a  slight 
chill,  fever,  headache,  and  pains  in  the  extremities,  in  the 
back,  and  in  the  epigastrium.  The  general  precede  the  gastric 
symptoms,  and  develop  independently  and  out  of  proportion 
to  the  gastritis.  Several  hours  after  the  commencement  there 
are  pains  in  the  stomach,  epigastric  tenderness,  nausea,  and 
vomiting.  The  vomit  consists  of  an  alkaline  fluid  containing 
mucus,  and,  incidentally,  sometimes  bile  and  undigested  food. 
The  bile  is  usually  absent,  except  after  retching,  and  the  de- 
velopment of  the  gastric  symptoms  is  in  no  relation  with  the 
diet  or  with  the  period  of  digestion,  and  there  is  no  gastric 
fermentation. 

The  fever  attains  its  highest  point  within  forty-eight  hours, 
and  oscillates  between  ioo°  and  103°  F.,  with  a  morning  remis- 
sion of  about  1°  F. ;  it  continues,  uncontrolled  by  quinin,  for 
ten  or  twelve  days,  and  drops,  with  a  greater  morning  remis- 
sion, in  two  or  three  days  to  the  normal  point. 

In  addition  to  the  initial  chill,  slight  rigors  may  occur  in 
the  course  of  the  disease.  The  bowels  may  be  constipated, 
but  there  are  usually  a  few  diarrheal  movements,  which  have 
none  of  the  characteristics  of  the  typhoid  stool.  The  pulse 
is  rapid,  the  patient  restless,  and  delirium  may  occur  in  the 
course  of  the  disease.  Insomnia  is  the  rule.  The  nervous 
symptoms,  apart  from  the  often  severe  initial  pains,  continue 
more  or  less  throughout  the  disease — headache,  restlessness, 
insomnia,  vertigo,  tinnitus  aurium,  prostration,  and,  with  the 
high  temperature,  sometimes  delirium. 

Diagnosis. — This  form  of  infectious  gastritis  may  be  con- 


GASTRITIS.  391 

founded  with  typhoid  fever.  But  the  step-like  rise  of  the 
temperature  during  the  first  week,  and  its  slow  remittent  de- 
cline during  the  third  or  fourth  week,  the  enlarged  spleen, 
the  characteristic  stool,  the  ileocecal  stagnation  and  gurgling, 
the  Widal  serum  sign,  and  the  eruption  are  all  absent.  A 
few  bronchial  rales  may  exist,  as  in  typhoid  fever ;  but  the 
gastritis  is  an  essential  and  distinctive  sign,  and  the  spleen  is 
never  palpable. 

From  the  fermentation  form  of  gastritis  and  the  severe 
form  of  simple  acute  gastritis  it  differs  in  the  absence  of  fer- 
mentation and  of  a  relation  with  alimentation  and  digestion, 
and  in  the  predominance  of  the  general  symptoms.  In  gastric 
fever  the  disturbance  of  the  system  is  much  greater  than  the 
disease  of  the  stomach  would  naturally  produce,  and  the  gen- 
eral and  the  local  symptoms  bear  no  close  relation  to  each 
other.  The  evolution  of  the  disease,  which  is  in  itself  dis- 
tinctively characteristic,  is  not  controlled  by  treatment. 

Treatment. — The  treatment  is  that  of  an  infectious  disease 
the  course  of  which  can  not  be  abridged  by  drugs.  Tepid 
sponging,  the  compress,  and  a  fluid  diet  are  indicated  to  con- 
trol the  fever  and  the  gastric  symptoms.  Calomel  may  be 
given  in  the  beginning,  and  often  exercises  a  good  influence 
on  the  symptoms  and  the  temperature.  The  nervous  symp- 
toms may  require  phenacetin,  but  it  is  best  not  to  disturb  the 
stomach  with  drues  oftener  than  can  be  avoided. 


III.    ACUTE  TOXIC  GASTRITIS. 

Acute  toxic  gastritis  is  an  inflammation  of  the  mucous 
membrane  of  the  stomach  excited  by  the  action  of  certain 
poisons  introduced  into  the  stomach  from  without. 

The  poisons  which  produce  an  injurious  effect  on  the 
stomach  may  be  formed  within  the  body  or  may  be  intro- 
duced from  without.  The  endogenous  poisons  are  brought  to 
the  stomach  by  the  blood.  We  have  nothing  to  do  here  with 
the  diseases  of  the  stomach  (among  which  may  be  gastritis) 
due  to  the  retention  or  the  excessive  formation  of  normal 
nutritive  or  secretory  products,  or  due  to  the  abnormal  sub- 
stances formed  by  disease  or  by  bacteria  within  the  body. 

Acute  toxic  gastritis  may  be  produced  by  alcohol,  by 
tobacco,  and  by  many  of  the  drugs  extensively  used  in  the 
treatment  of  disease.  The  essential  oils  and  resins,  the 
iodids,  the  preparations  of  mercury,  the  bromids,  the  salicy- 
lates, arsenic,  purgatives,  iron  and  its  compounds,  and  a  large 


392  DISEASES  OF  THE  STOMACH. 

number  of  other  drugs,  when  given  improperly,  or  for  a  long 
time,  produce  gastritis.  But  it  would  not  be  wise  to  say  more 
of  the  serious  injury  which  is  often  done  while  conscientiously 
endeavoring  to  do  good.  Acute  toxic  gastritis  is,  however, 
often  produced  by  poisons  which  have  been  taken  by  acci- 
dent or  for  suicidal  purposes,  or  which  have  been  adminis- 
tered with  forethought  and  malice.  Some  of  the  most  common 
forms  of  it  will  be  briefly  described. 

All  poisons  are  not  capable  of  exciting  an  acute  gastritis. 
As  regards  their  action  on  the  stomach,  poisons  may  be 
divided  into  three  classes. 

1.  Those  which  enter  into  chemical  combination  with  the 
tissues,  either  dissolving  the  cells,  as  do  the  caustic  alkalies, 
or  coagulating  the  protoplasm,  as  does  alcohol,  or  uniting 
with  their  constituents,  as  do  phosphorus  and  the  mineral 
acids.     These  are  chemically  destructive  poisons. 

2.  Those  which  irritate  and  excite  inflammation  of  the 
glandular  layer. 

3.  Those  which  produce  no  anatomical  change  in  the 
mucous  membrane  perceptible  during  life  or  visible  after 
death.  This  class  consequently  plays  no  part  in  the  etiology 
of  toxic  gastritis. 

(a)  Poisonous  Acids. — The  stronger  acids  brought  in  con- 
tact with  the  mucous  membrane  of  the  stomach  directly, 
produce  death  of  the  tissues  by  dehydrating,  coagulating,  or 
combining  with  the  constituents  of  the  cells,  for  which  they 
have  strong  chemical  affinities ;  and  by  irritation  of  the  adja- 
cent parts  they  excite  inflammation,  which  may  be  so  intense 
as  to  lead  to  local  death.  The  separation  of  the  necrosed 
tissues  is  a  reactive  process,  which  may  be  followed  by  cica- 
tricial healing,  or  by  regeneration,  if  the  action  has  been 
superficial. 

Pathological  Anatomy. — The  stomach  is  the  center  of  the 
destructive  changes  produced  by  swallowing  corrosive  acids, 
being  the  place  where  they  are  first  arrested,  and  where  they 
long  remain.  The  action  on  the  .stomach  is  conditioned  by 
the  quality,  the  concentration,  and  the  chemical  affinities  of 
the  acid,  and  by  the  quantity  and  the  nature  of  the  contents 
of  the  stomach  at  the  time  when  the  poison  is  swallowed.  In 
small  quantities  the  action  is  most  intense  and  may  be  con- 
fined to  the  region  about  the  cardia  and  the  lesser  curvature, 
along  which  the  acid  flows  to  and  around  the  pylorus.  Con- 
sequently a  very  small  quantity,  after  recovery  by  cicatriza- 
tion, is  likely  to  leave  serious  and  obstructive  deformity  of 
the  orifices.     In  larger  quantity,  the  action  is  more  difl"used 


GASTRITIS.  393 

and  general,  but  is  deepest  along  lines  marked  by  the  tops  of 
the  folds  into  which  the  mucous  membrane  is  thrown  by  the 
strong  contortions  of  the  stomach.  The  depth  of  the  direct 
destruction  varies  according  to  the  quantity,  the  nature,  and 
the  duration  of  the  action  of  the  poisons.  The  coagulation 
necrosis  may  extend  rapidly  through  the  entire  thickness  of 
the  wall,  may  undergo  dissolution,  and  thus  produce  perfora- 
tion. The  coagulation  of  the  blood  may  extend  far  into  the 
veins,  reaching  the  liver,  the  right  heart,  and  the  lungs.  Such 
direct  and  extensive  destruction  and  coagulation  are  rapidly 
fatal.  Where  the  violence  is  less  brutal,  the  direct  chemical 
necrosis  is  more  superficial,  and  the  reactive  inflammation  may 
separate  the  slough,  and,  with  granulation  formation,  accom- 
panied by  free  suppuration  and  by  bacterial  infection,  may 
ultimately  end  with  a  cicatrix  which  may  inclose  the  remains 
of  glands.  Or  the  inflammation,  intense  and  hemorrhagic, 
may  end  in  local  death  and  an  extension  of  the  loss  of  sub- 
stance. The  necrosis  may  be  superficial,  but  may  occur  in 
patches;  and  recovery  may  leave  a  deformed  stomach,  with 
preservation  of  more  or  less  of  its  glandular  structure. 

Clinical  Description. — The  symptoms  are  due  to  the  local 
action  of  the  poison  on  the  tissues  with  which  it  comes  in 
contact,  to  the  diminished  alkalinity  of  the  blood,  and  to  the 
toxic  nephritis. 

The  local  symptoms  develop  immediately,  and  are  ex- 
tremely violent.  The  pain  is  burning  and  horrible  in  the 
mouth,  throat,  the  beginning  of  the  esophagus,  at  the  point 
where  it  passes  the  left  bronchus,  immediately  above  the 
cardia,  and  in  the  stomach.  The  stomach  is  in  tonic  spasm, 
and  the  excruciating  pain  radiates  over  the  abdomen.  The 
patient  writhes  in  agony,  the  pulse  is  small  and  weak,  and 
the  body  covered  with  a  cold  perspiration.  A  brownish 
saliva  flows  from  the  mouth,  and  intense  dyspnea  may  be 
present  if  some  of  the  acid  has  entered  the  larynx  or  if  there 
is  a  rapidly  developed  edema  of  the  glottis.  Saliva,  which 
may  be  colored  with  altered  blood,  flows  from  the  mouth; 
and  vomiting,  aided  by  unquenchable  thirst,  dysphagia,  in- 
testinal pain,  mucous  and  bloody  diarrhea,  and  tenesmus,  adds 
to  the  miseries  of  the  patient,  who  sinks  rapidly  into  collapse, 
and  dies  within  from  two  to  twenty-four  hours. 

The  local  symptoms  may  be  less  violent,  and  the  patient 
may  live  long  enough  for  the  blood  and  renal  symptoms  to 
develop.  If  the  stomach  is  not  already  empty,  the  vomiting 
may  be  delayed.  The  vomit  consists  of  the  contents  and 
mucus,    colored    with   hematin,  and  of  the  acid  swallowed. 


394  DISEASES  OF  THE   STOMACH. 

The  urine,  which  is  passed  with  pain,  contains  serum  albumin 
and  globulin,  hematin,  and  casts. 

The  diminished  alkalinity  of  the  blood  may  add  to  the 
nervous  symptoms.  If  a  large  dose  of  an  acid  be  given  to  a 
herbivorous  animal,  it  falls  at  once  into  a  stupor,  and  dies 
before  the  blood  becomes  acid.  Carnivorous  animals  and 
man  have  a  greater  power  of  neutralization  ;  but  the  dimin- 
ished alkalinity  of  the  blood  will  produce  somnolence,  stupor, 
or  coma,  in  proportion  to  its  degree. 

The  symptoms  due  to  the  renal  lesion  are  those  of  acute 
parenchymatous  nephritis  with  intense  irritation,  but  no 
edema  develops. 

The  subsequent  course  is  marked  by  the  combined  local, 
nervous,  and  renal  symptoms.  The  temperature,  subnormal 
in  the  beginning,  rises  a  few  degrees.  The  dangers  do  not 
end  with  recovery,  for  the  deformities  which  result  from 
cicatrization  may  compromise  e.xistence. 

Diagnosis. — The  sudden  beginning,  and  the  violence  of  the 
symptoms  in  the  midst  of  health,  would  suggest  poisoning. 
But  the  patient  may  already  have  been  ill  before  the  acid 
was  swallowed.  The  excessive  acidity  of  the  vomit  would 
create  suspicion.  The  diagnosis  of  corrosive  poisoning 
will  be  given  by  inspection  of  the  mouth,  and  the  color  of 
the  necrosed  spots  may  suggest  the  particular  acid.  The 
SN'mptom-group,  and  the  examination  of  the  urine  and  the 
vomit,  reveal  the  particular  acid  to  which  the  gastritis  and  its 
treatment  stand  in  direct  relation. 

In  sulphuric-acid  poisoning  the  local  action  is  very  de- 
structive, and  grayish-brown  eschars  are  found,  which  e.xtend 
deep  into  the  tissues,  the  surface  being  hard  and  parchment- 
like ;  the  toxic  nephritis  is  likewise  intense,  and  the  duodenum 
and  the  small  intestine  may  be  inflamed  and  ulcerated  in  spots. 
The  cicatrices  are  large,  and  the  prognosis  must  be  guarded. 
Even  after  resolution  the  strictures  offer  little  hope  of  relief 
by  surgical  operations.  The  fatal  dose,  on  an  empty  stomach, 
is  about  five  grams.     Perforation  is  frequent. 

Nitric  acid  produces  lesions  similar  to  those  produced  by 
sulphuric  acid,  but  perforation  is  less  frequent,  and  the  eschars 
are  brown  on  account  of  the  formation  of  xanthoproteinic 
acid.     The  fatal  dose  is  six  to  eight  grams. 

Hydrochloric  acid  produces  a  grayish  eschar  on  the  mu- 
cous membrane  and  no  cauterization  in  the  corners  of  the 
mouth,  or  but  rarely.  The  eschar  may  be  yellowish,  like  that 
of  nitric  acid.  The  toxic  nephritis  is  rare,  and  strictures  are 
not    so    frequent  with    hydrochloric    and  nitric  as   with   sul- 


GASTRITIS.  395 

phuric  acid.  But  the  nervous  symptoms  are  more  promi- 
nent, and  death  may  occur  in  collapse,  in  convulsions,  or  in 
coma  before  vomiting  sets  in.  Perforation  is  very  rare. 
Lavage  is  permissible. 

Chromic  acid  and  its  salts  are  very  destructive  caustics,  and 
the  toxic  dose  is  very  small — less  than  ^  of  a  grain.  The  color 
of  the  eschar  on  the  skin  and  the  mucous  membrane  is  yel- 
lowish-white, becoming  grayish-brown,  and  the  vomit,  which 
is  rapidly  produced,  is  colored  yellowish-red  or,  by  oxidation, 
may  be  green.  It  produces  severe  abdominal  pain,  diarrhea, 
cramps,  collapse,  cyanosis,  and  death  ;  or  the  patient  may 
recover  after  showing  yellow  sclerotics,  toxic  nephritis,  and 
anuria.  The  temperature  may  rise  and  the  uremia  may  be 
the  cause  of  death.  The  nephritis  often  becomes  chronic. 
The  alkalies  neutralize  the  chromic  acid,  but  form  poisonous 
salts.  Acetate  of  iron  is  the  best  antidote.  The  stomach 
may  be  washed  out  with  a  -^-^j  per  cent,  solution  of  nitrate  of 
silver,  as  the  silver  chromate  is  insoluble.  The  intestines  are 
more  involved  than  in  other  acid  poisonings,  and  with  the 
gastritis  is  associated  enteritis,  often  with  large  ulcers,  par- 
ticularly in  the  colon. 

Acetic  acid  may  also  produce  gastritis,  and  is  of  special 
interest  on  account  of  its  wide-spread  use  as  a  condiment  and 
its  production  in  the  stomach  by  fermentation.  Concentrated, 
it  is  as  destructive  as  the  strong  mineral  acids,  and  produces 
a  white  eschar,  cicatricial  deformities,  and,  in  large  doses, 
nephritis.  It  is  oxidized  and  eliminated  as  carbonates,  ren- 
dering the  urine  neutral  or  alkaline.  Like  tartaric  and  lactic 
acids,  long  continued  in  small  doses,  it  produces  chronic 
gastritis. 

Oxalic  acid  produces  a  whitish  eschar,  surrounded  by  a 
zone  of  intense  inflammation,  which  separates  with  difficulty. 
The  vomit  is  seldom  colored,  and  there  is  no  hemorrhage. 
This  acid  has  been  found  in  the  stomach  as  a  bacterial 
product.  It  produces,  in  addition  to  the  local  symptoms, 
violent  convulsions  and  rapid  death,  through  its  action  on 
the  nervous  system.  It  excites  also  toxic  nephritis,  anuria, 
colitis,  and  enteritis,  with  punctate  hemorrhages  and  ulcer- 
ation. 

Formic  acid  excites,  locally,  an  intense  inflammation,  and 
in  sufficient  concentration  is  also  a  caustic.  It  is  an  oxidation 
product  of  gastric  fermentation,  and  consequently  is  of  double 
interest  to  the  practitioner.  It  excites  nephritis,  and  is  a 
selective  poison  for  the  kidneys  unless  oxidized  into  car- 
bonic acid  before  elimination. 


396  DISEASES  OF  THE  STOMACH. 

Treatment. — The  immediate  treatment  consists  in  the 
administration  of  the  chemical  antidote.  This  is  not  the 
same  for  all  acids.  Magnesia  usta  is  the  best  antidote 
for  the  mineral  acids,  but  other  alkalies  may  also  be  used. 
The  carbonates  of  the  alkalies  should  be  avoided,  on 
account  of  the  danger,  in  severe  cases,  of  rupture  of  the 
necrosed  stomach.  But  delay  is  dangerous,  and  may  be 
fatal,  and  whatever  is  at  hand  should  be  given — as  soup,  milk, 
white  of  &^g,  chalk,  scraping  from  plaster  walls,  or  soap. 

The  aftertreatment  consists  in  the  employment  of  remedies 
to  cure  the  local  inflammations  and  to  control  the  symp- 
toms. The  nourishment  and  water  may  have  to  be  given 
exclusively  per  rectum.  Food  given  by  the  mouth  should  be 
fluid  and  non-stimulating,  as  milk  or  cereal  gruels.  Opium 
may  have  to  be  freely  used,  and  healing  of  the  ulcers  may 
be  favored  by  large  doses  of  bismuth.  The  collapse  may 
be  treated  with  camphorated  oil  and  strychnin,  and  the  coma 
by  increasing  the  alkalinity  of  the  blood  by  free  hypoder- 
mic or  intravenous  injections  of  sodium  carbonate. 

{b)  Caustic  Alkalies. — The  caustic  alkalies,  like  the  caustic 
acids,  produce  local  death  and  reactive  inflammation.  The 
acids  coagulate  the  protoplasm,  and  form  dry,  hard,  parch- 
ment-like eschars,  sharply  limited  beneath ;  the  alkalies 
liquefy  the  protoplasm,  and  extend  very  deep  into  the  tissues, 
and  the  eschar  is  softer  and  like  false  membrane.  The  mus- 
cular tissue  is  rapidly  disintegrated;  the  connective  tissue  is 
but  little  affected;  and  the  nerves,  except  the  end  plates,  are 
left  chemically  intact,  to  undergo  degeneration.  They  do 
not  act,  like  the  acids,  on  the  kidne\'S  and  the  blood ;  the  vomit 
is  alkaline;  the  urine,  neutral  or  slightly  alkaline  ;  and  the  re- 
active inflammation  is  more  diffuse.  Cicatricial  deformity  is 
a  legacy  of  both  forms  of  poisoning.  The  treatment  consists 
in  the  neutralization  of  the  alkali  by  vinegar  or  by  tartaric 
acid,  and  in  the  employment  of  medication  to  relieve  the 
local  inflammation  and  the  complications  and  to  control  the 
symptoms. 

The  symptoms  are  intense  pain,  vomiting,  collapse,  death 
in  convulsions,  or  from  a  terminal  perforation  peritonitis;  or, 
if  the  acute  stage  is  safely  passed,  the  symptoms  are  those  of 
the  intense  reactive  inflammation.  The  vomit  is  brownish  from 
altered  blood,  intensely  alkaline,  tough,  and  ropy.  Ammonia 
is,  in  contradistinction  to  caustic  potash  and  soda,  a  respira- 
tory stimulant,  and  may  produce  a  toxic  nephritis. 

The  inspection  of  the  mouth,  the  symptom-group,  and 
the  properties  of  the  vomit  give  the  diagnosis. 


GASTRITIS.  397 

[c]  Metallic  Poisons. — Arsenic,  phosphorus,  and  antimony 
do  not  belong  to  the  caustic  poisons.  The  gastritis  excited 
by  them  is  not  in  itself  characteristic,  but  all  of  them  lead  to 
fatty  degeneration  of  the  parenchyma  of  the  various  organs 
of  the  body,  including  the  glands  of  the  stomach.  Arsenic 
may  produce  an  intense  hemorrhagic  gastritis,  with  the  forma- 
tion of  ulcers;  phosphorus  may  excite  little  inflammation; 
antimony  may  cause  more  intense  irritation  than  arsenic, 
the  epithelium  being  destroyed  or  raised  here  and  there  in 
numerous  vesicles  and  pustules. 

The  gastric  symptoms  of  phosphorus-poisoning  are  usually 
delayed  several  hours,  unless  the  stomach  contains  fat  in  some 
form,  and  may  be  very  slight.  After  six  or  eight  hours  there 
may  be  nausea  and  vomiting  ;  the  vomit  is  seldom  bloody,  and 
contains  phosphorus.  During  the  first  week  the  liver  en- 
larges, the  spleen  remaining  normal  in  size.  With  the  fatty 
degeneration  of  the  liver  icterus  also  appears,  and  sometimes 
fever.  During  this  stage  death  may  occur  suddenly  from 
cholemia.  A  sequel,  should  recovery  take  place,  is  more  or 
less  complete  gastric  atrophy. 

Arsenical  poisoning  is  accompanied  by  more  pronounced 
symptoms,  beginning,  after  an  interval  of  an  hour  or  two, 
with  burning  in  the  mouth,  vomiting,  and  cholera-like  stools, 
cramps  in  the  extremities,  and  collapse.  The  vomit  is  not 
colored  with  blood,  but  contains  the  poison.  If  the  patient 
survive  the  initial  stage,  nervous  symptoms  may  appear — 
paralysis  of  the  sympathetic  or  neuritis.  Anuria  may  result 
from  a  toxic  nephritis.  Recovery  is  likely  to  leave  perma- 
nent effects,  from  the  action  of  the  poison  on  the  abdominal 
sympathetic  and  from  gastro-intestinal  atrophy. 

Antimony  leaves  its  trace  in  the  inflammation  and  vesicles 
of  the  mouth,  but  its  gastro-intestinal  symptoms  are  very 
much  like  those  of  arsenic.  Influence  upon  the  nervous 
system,  like  that  exercised  by  arsenic,  is  not  found  in  anti- 
monial  poisoning. 

The  diagnosis  is  dependent  on  the  symptom-group,  and  on 
the  detection  of  the  poison  in  the  vomit,  the  stools,  or  the 
urine. 

Treatment. — The  indication  in  the  treatment  of  phosphorus- 
poisoning  is  to  remove  the  phosphorus  before  its  absorption 
takes  place.  The  only  means  of  doing  this  thoroughly  is  with 
the  stomach-tube.  The  stomach  should  be  thoroughly  washed 
out  with  warm  water;  then  with  a  one  per  cent,  solution  of 
sulphate  of  copper,  followed  by  the  introduction  of  magnesia 
usta.     The  stomach  is  further  washed  out  with  water,  and  a 


398  DISEASES  OF  THE  STOMACH. 

full  dose  of  Epsom  salts  is  left  therein.  After  the  action  of 
the  saline,  the  colon  should  be  thoroughly  washed  out.  In 
this  manner  the  poison  is  removed  from  the  digestive  tube. 
Fats  must  be  carefully  excluded  from  the  diet.  The  after- 
treatment  is  that  of  the  symptoms  and  the  complications. 

Arsenical  poisoning  is  treated  also  by  immediate  lavage,  to 
which  calcined  magnesia  is  added.  The  usual  antidote  (the 
freshly  magnesia-precipitated  subsulphate  of  iron)  is  then 
introduced  and  left  in  the  stomach.  The  same  .precaution 
should  be  taken  to  evacuate  the  whole  bowel  with  a  clyster 
to  which  glycerin  may  be  added,  and  followed  by  lavage  of 
the  colon.  The  aftertreatmcnt  is  that  of  the  gastro-enteritis, 
the  gross  symptoms,  and  the  complications. 

The  treatment  of  antimonial  poisoning  is  conducted  on  the 
same  principles.  The  lavage  water  should  contain  about 
one  per  cent,  of  tannin.  The  evacuation  of  the  intestines 
should  also  receive  attention,  and  the  gastro-enteritis  should 
be  treated  in  the  usual  manner. 


CHRONIC  GASTRITIS. 

The  anatomical  and  clinical  conceptions  of  chronic  inflam- 
mation of  the  mucous  membrane  of  the  stomach  are  widely 
different.  If  all  the  cases  are  to  be  classified  as  chronic  gas- 
tritis in  which  marked  anatomical  changes  (which  assume  the 
characteristics  of  chronic  inflammation)  are  found  at  the 
autopsy,  then  this  is  unquestionably  the  most  frequent  of  all 
the  diseases  of  the  stomach.  Chronic  gastritis  is  the  almost 
constant  accompaniment  of  the  last  stages  of  all  chronic  dis- 
eases. This  terminal  gastritis  should  be  placed  among  the 
vicious  circles  of  the  stomach,  along  with  all  cases  secondary 
to  a  disease  of  another  organ  than  the  stomach,  and  present- 
ing anatomical  or  clinical  peculiarities. 

Gastritis  is  often  a  complication  of  a  chronic  disease  of  the 
stomach;  and  neither  ulcer,  nor  carcinoma,  nor  pronounced 
myasthenia,  nor  obstructive  retention,  completes  its  evolution 
without  the  development  of  gastritis.  The  clinical  conception 
excludes  this  complicating  gastritis.  But  ulcer,  carcinoma, 
obstructive  retention,  and  motor  insufficiency  may  appear  in 
the  course  of  chronic  gastritis,  and  only  a  knowledge  of  the 
development  of  the  particular  case  could  enable  us  to  decide 
which  is  the  primary  and  which  is  the  complicating  disease. 
Many  of  the  diseases  of  the  stomach  are  links  in  the  evolu- 
tion of  one  process. 


GASTRITIS.  399 

Chronic  gastritis,  as  a  distinct  clinical  disease,  is  a  chronic 
inflammation  of  the  glandular  coat  of  the  stomach,  not  devel- 
oping in  the  course  or  as  a  consequence  of  any  other  chronic 
disease  of  the  stomach.  Before  the  clinical  disease  can  be 
established,  the  characteristic  symptoms,  the  evolution,  and 
the  objective  signs  must  be  demonstrated,  and  a  chronic 
associated  and  causal  disease  must  be  excluded.  Some 
authors  also  exclude  from  the  clinical  conception  of  this 
disease  all  cases  accompanied  by  a  persistent,  excessive, 
specific  secretion.  A  well-marked  clinical  form  of  chronic 
gastritis  (hypersthenic  form)  is  classified  and  described  among 
the  "  neuroses  "  in  nearly  all  the  text-books.    This  is  an  error. 

Etiology. — Chronic  gastritis  is  most  frequent  in  the  middle 
period  of  life.  It  is  no  less  common  in  old  age,  but  is  then 
more  often  latent. 

If  it  be  remembered  how  many  morbific  influences  have  a 
special  afifinity  for  this  organ,  it  will  be  no  wonder  that  path- 
ologists so  rarely  find  a  healthy  stomach  after  the  beginning 
of  adult  life.  Chronic  gastritis  frequently  follows  the  acute 
disease.  All  the  infectious  fevers  and  inflammations  affect 
the  stomach,  and  often  produce  anatomical  changes  in  the 
mucous  membrane.  There  exists  no  serious  disease  of  an 
important  organ  of  the  body,  or  of  nutrition,  that  may  not 
in  itself  be  the  efficient  or  predisposing  cause  of  gastritis.  It 
may  become  a  complication  of  another  anatomical  disease  of 
the  stomach,  or  may  develop  as  a  consequence  of  the  chronic 
dynamic  affections.  But  if  all  these  causes  were  inactive, 
chronic  gastritis  would  not  be  a  rare  disease,  on  account  of 
the  irritants  which  are  introduced  into  the  stomach  or  which 
develop  in  it.  All  the  causes  of  acute  gastritis,  acting  with 
moderate  violence  during  a  long  period, — the  products  offer- 
mentation,  coarse  food,  excess  of  condiments,  abuse  of  alcoholic 
drinks,  prolonged  use  of  the  bitter  aromatic  drinks,  swallow- 
ing saliva  impregnated  with  nicotin  or  tobacco  juice,  abuse 
of  purgatives  and  irritating  drugs, — are  so  many  directly  act- 
ing causes  of  the  chronic  disease. 

Pathological  Anatomy — The  pathological  anatomy  of 
chronic  gastritis  is  extremely  complex  and  variable.  There 
is  no  constant  relation  between  the  cause  and  the  morbid 
anatomy.  During  the  initial  period,  it  is  true,  the  inflamma- 
tory lesions  due  to  the  irritation  of  the  contents  are  more 
pronounced  in  the  superficial  part  of  the  mucous  membrane, 
whereas  those  excited  by  blood  or  by  circulation  changes 
are  most  marked  in  the  interglandular  tissue  and  in  the  sub- 
mucosa.     But  the  evolution  of  the  pathological  anatomy  soon 


400 


DISEASES  OF  THE  STOMACH. 


conceals  any  relation  that  may  have  at  one  time  existed  with 
the  natural  mode  of  action  of  the  exciting  cause.  The  fol- 
lowing diagram  shows  clearly  and  at  a  glance  this  conception 
of  the  evolution  of  chronic  gastritis. 

Every  case  of  chronic  gastritis  displays  the  common  signs 
of  this  form  of  inflammation — disordered  circulation,  small 
round-cell  infiltration,  cell  proliferation,  and  cell-degeneration. 
Hemorrhagic  erosion  and  superficial  ulceration  may  be  asso- 
ciated with  any  of  the  forms.     The  ulcers  may  be  few  or  innu- 


Fig.  19. — The  evolution  of  chronic  gastritis. 


merable,  and  vary  in  size  from  a  pin-head  to  a  small  hand. 
The  grayish-brown,  thickened  mucous  membrane  may  be 
marked  by  fine  ramifications  of  dilated  blood-vessels.  But  the 
inflammatory  changes  may  predominate  in  particular  compo- 
nents of  the  mucous  membrane,  and  thus  produce  correspond- 
ing pathological  forms.  Three  anatomical  varieties  of  the 
disease  might  be  described — the  catarrhal,  the  glandular,  and 
the  interstitial.  Any  one  of  these  varieties  may  terminate  in 
atrophy  of  the  gastric  glands. 


GASTRITIS.  401 

But  this  anatomical  classification  does  not  represent  the 
clinical  forms  of  the  disease,  for  interstitial  gastritis  has  no 
characteristic  clinical  expression  and  no  characteristic  func- 
tional signs.  The  diagram  which  illustrates  the  evolution  of 
gastritis  makes  clear  the  fact  that  interstitial  gastritis  may 
produce  catarrhal  gastritis,  or  it  may  produce  proliferating 
glandular  gastritis,  or,  finally,  it  may  terminate  in  anadenia 
gastrica  as  a  result  of  granular  or  mucoid  degeneration  of  the 
chief  cells  of  the  gastric  glands.  Moreover,  interstitial  gas- 
tritis nearly  always  accompanies  both  chronic  gastric  catarrh 
and  glandular  gastritis.  Interstitial  gastritis  will,  conse- 
quently, not  be  described  as  a  distinct  clinical  form. 

It  requires  no  very  great  ingenuity  to  multiply  the  ana- 
tomical forms  of  chronic  gastritis,  for  the  primary  forms  do 
not  preserve  their  identity  throughout  their  development. 
The  characteristics  of  one  stage  lose  their  predominance  at  a 
further  stage  of  the  evolution  of  the  disease.  Nature  mixes 
the  anatomical  forms  at  various  stages,  and  produces  numerous 
varieties.  Furthermore,  the  gastritis  does  not  develop  with 
equal  rapidity  over  the  whole  surface  of  the  mucous  mem- 
brane, nor  is  it  of  the  same  character  everywhere.  It 
becomes  necessary,  therefore,  to  introduce  some  general 
characteristic  which  displays  the  predominant  condition  of 
the  whole  mucous  membrane.  The  predominant  condition  of 
the  mucous  membrane  is  displayed  by  the  functional  signs 
and  by  the  clinical  expression. 

In  a  large  group  of  cases  the  special  secretion  of  the 
stomach  is  constantly  diminished.  The  contents  of  the  test- 
breakfast  contain  less  hydrochloric  acid  (H  +  C)  and  less 
ferments  than  normal.  Mucus  is  secreted  in  excess.  There 
is  no  spasm  of  the  pylorus,  and  the  stomach  empties  itself  in 
a  normal  manner.  The  appetite  is  diminished  or  lost.  Pain 
is  rare.  There  may  be  nausea,  and  after  meals  the  stomach 
feels  overloaded.  The  signs  and  symptoms  are  those  of  de- 
pression. The  manifestations  are  not  violent.  There  is  no 
show  of  strength,  but  everything  is  dull  and  weak.  The 
special  acid-  and  ferment-secreting  cells  are  inactive  and  de- 
generate, and  there  may  be  active  connective-tissue  produc- 
tion. Only  the  cylindrical  cells  are  irritable  and  secrete  a 
large  excess  of  mucus.  The  gastritis  is  catarrhal  in  its  be- 
ginning and  evolution,  and  the  dynamic  expression  is 
asthenic. 

Another  group  of  cases  are  violent  in  their  manifestations. 
All  the  signs  are  those  of  great  irritabilit)^  General  gastric 
sensation  is  acute,  and  the  appetite,  when  not  dulled  by  pain, 
26 


402  DISEASES  OF  THE  STOMACH. 

is  sharp.  Secretion  is  excessive — excess  of  acids  and  fer- 
ments and  a  more  than  normal  quantity  of  mucus.  Tlie 
pylorus  may  be  closed  by  spasm,  and  there  may  be  gastric 
cramps.  The  inflammation  is  glandular  and  productive  in  its 
predominance  and  evolution.  The  dynamic  expression  is 
hypersthenic. 

A  third  group  of  cases  is  characterized  b\'  a  special 
causation  and  by  a  peculiar  evolution.  The  clinical  expres- 
sion is,  unlike  that  of  the  two  other  groups,  sometimes  latent, 
sometimes  violent.  The  mucous  membrane  is  exceedingly 
vulnerable,  and  gastric  secretion  progressively  diminishes 
until  it  almost  disappears.  The  process  is  atrophic,  and  the 
glands  and  the  cylindrical  surface  cells  disappear,  and  leave  a 
layer  composed  of  connective  tissues  infiltrated  with  em- 
bryonic cells  and  leukcoytes. 

We  recognize,  therefore,  three  distinct  clinical  and  ana- 
tomical forms  of  chronic  gastritis — viz  :  (i)  Gastritis  catarrh- 
alis  chronica,  or  chronic  asthenic  gastritis ;  (2)  gastritis 
glandularis  proliferans,  or  chronic  hypersthenic  gastritis;  (3) 
gastritis  glandularis  atrophicans,  or  progressive  atrophy  of 
the  cfastric  crlands. 


I.    GASTRITIS  CATARRHALIS  CHRONICA,  OR  CHRONIC 
ASTHENIC  GASTRITIS. 

Pathological  Anatomy. — The  mucous  membrane,  in  chronic 
asthenic  gastritis,  is  covered  with  a  thick  layer  of  tough 
mucus  mixed  with  a  large  number  of  cells,  which  are  in  part 
desquamated  cylindrical  cells,  in  part  wandering  leukocytes, 
and  in  part  blood-corpuscles.  The  color  may  be  reddish- 
brown,  or  gray,  or  darkly  pigmented.  The  coloration  of  the 
pyloric  region  is  usually  diffuse,  while  that  of  the  rest  of  the 
mucous  membrane  is  mottled.  The  coloration  is  due  to  more 
or  less  altered  blood  pigment  and  cells  mi.xed  with  mucus.  The 
mucous  membrane  is  swollen,  and  the  swelling  is  the  result 
of  edema,  of  infiltration  of  the  connective  tissue,  and  of  en- 
larged, obstructed  glands.  The  round-cell  infiltration  of  the 
connective  tissue  may  be  limited  to  the  superficial  or  mucous 
division  of  the  mucosa  ;  or  to  the  interglandular  and  the  sub- 
glandular  connective  tissue;  or  it  ma\-  extend  to  the  sub- 
mucosa  and  to  the  muscular  layer.  The  infiltration  and 
swelling  is  most  intense  in  the  pyloric  region,  and  may 
diminish  the  size  of  the  pyloric  opening.  In  old  cases  the 
mucous  membrane  may  become  mammellated,  and  the  prom- 


GASTRITIS. 


403 


inences  may  resemble  polypi.  The  surface  may  be  studded 
with  little  vesicles  on  the  villosities,  or  there  may  be  hemor- 
rhagic erosions,  catarrhal  ulcers,  or  very  small  ulcers  with 
the  opening  of  a  gland  in  the  center. 

The  microscopic  appearance  of  a  transverse  section  of  the 
mucous  membrane  is  very  interesting.  On  account  of  the  in- 
filtration of  the  interglandular  connective  tissue  only  about 
one-half  the  number  of  ducts  appear  in  the  field,  as  can  be 
seen  in  a  cut  of  the  normal  mucous  membrane  made  parallel 
to  the  surface  through  the  mucous  layer  of  the  mucosa.    The 


■'•  ,*V; 


Fig.  20. — Gastritis  clironica  catarrhalis.     X  240.     (Authors'  specimen.) 


connective  tissue  is  infiltrated  with  small,  round,  nucleated 
embryonic  cells,  and,  although  the  intensity  of  the  infiltration 
varies,  and  may  be  diffuse  or  in  patches,  it  always  becomes 
less  and  less  as  the  eye  goes  from  the  surface  to  the  sub- 
mucosa.  Mixed  with  the  embryonic  cells  are  wandering 
leukocytes  and  hyaline  bodies.  The  hyaline  bodies  are  the 
granules  of  disintegrated  leukocytes.  Many  of  the  leuko- 
cytes possess  oxyphile  granules,  and  they  wander  between 
the  cylindrical  cells  to  the  surface,  or  into  the  mucous 
division    of  the  ducts  of  the  glands.     Some    of  them  worm 


404 


DISEASES  OF  THE  STOMACH. 


their  way  directly  through  the  cylindrical  cells,  and  may 
be  recognized  therein  by  their  form,  by  their  structure,  and 
by  their  affinities  for  stains.  The  cylindrical  cells,  which 
cover  the  villosities  and  line  the  ducts  of  the  glands  down  to 
the  necks  of  the  tubules,  desquamate,  reproduce  rapidly, 
become  striated  along  their  free  ends,  and  degenerate  into 
beaker  cells.  The  border  cells  are  very  few,  which  is  in  keep- 
ing with  the  functional  inactivity  of  the  glands.  The  nuclei 
and  the  cytoplasm  of  the  young  cells  stain  deeply,  and  are 
readily  distinguishable  from  the  older  and  paler  cells.     The 


»'^**^  .^ 


■'S 


Fig.  21.— Gastritis  chronica  catairhalis  et  iiilerslitialis.     X  115.    (.\iitliors' specimen.) 


nuclei  of  some  of  the  cylindrical  cells  may  be  seen  in  the 
process  of  nuclear  division,  and  the  division  may  be  asym- 
metrical or  typical.  Three  or  four  such  cells  may  be  seen  in 
the  duct  of  a  gland  and  here  and  there  along  the  surface  of 
the  mucous  membrane.  Beaker  cells  are  not  found  in  health, 
but  are  common  in  gastric  catarrh.  The  gastric  glands  may 
be  elongated  and  dilated  as  a  result  of  obstruction  of  their 
ducts  by  swollen  and  desquamated  cylindrical  cells.  The 
chief  cells  may  undergo  mucoid  degeneration  and  vacuola- 
tion.     The  degenerated  chief  cells  may  be  replaced  by  cylin- 


GASTRITIS.  405 

drical  cells,  the  regeneration  proceeding  from  the  cells  lining 
the  necks  of  the  glands,  which  are  thus  changed  from  peptic 
into  mucous  glands.  Catarrhal  gastritis,  in  its  evolution,  be- 
comes a  mixed  gastritis,  and  may  terminate  in  anadenia  gas- 
trica.  The  excessive  secretion  of  mucus  and  the  diminished 
secretion  of  acid  and  ferments  are  the  natural  consequences 
of  the  anatomical  lesions — viz.,  the  irritable  hyperplasia  and 
excessive  activity  of  the  cylindrical  cells,  the  degeneration 
and  reversion,  respectively,  of  the  cylindrical  cells  into  beaker 
cells  and  into  striated  (ciliated)  columnar  cells,  the  infiltration 
of  the  mucous  division  of  the  mucosa,  and,  to  a  lesser  degree, 
of  the  interglandular  and  subglandular  connective  tissue. 
The  chief  cells  may  remain  normal  or  degenerate,  and  the 
border  cells  are  very  few  in  number,  in  keeping  with  the 
inactivity  of  glandular  secretion.  The  peptic  glands  may  be 
converted  into  mucous  glands,  or  they  may  disappear;  the 
glandular  division  of  the  mucosa  being  transformed  into  an 
infiltrated  layer  containing,  here  and  there,  the  remains  of  a 
peptic  gland,  or  invaded  by  the  growth  and  elongation  of  the 
portion  of  the  duct  which  is  normally  lined  with  cylindrical 
cells.  Eventually  the  mucous  division  of  the  mucosa  may 
undergo  atrophy. 

Clinical  Description. — The  symptoms  of  chronic  asthenic 
gastritis  are  very  variable.  It  may  be  latent  for  months,  or 
even  throughout  its  anatomical  evolution.  In  its  simple  form 
it  is  a  painless  disease,  and  the  gastric  discomfort,  fullness,  or 
weight  are  the  only  abnormal  sensations  of  which  the  patient 
complains.  The  other  gastric  symptoms  are  belching  and 
sometimes  nausea  and  vomiting.  The  belching  is  not  a  re- 
sult of  gas  formation  in  the  stomach,  but  it  is  induced,  re- 
flexly  or  voluntarily,  to  relieve  the  sensation  of  fullness.  The 
appetite  may  be  normal,  but  is  more  often  diminished  or 
easily  satisfied.  Sometimes  sour,  spicy,  and  highly  seasoned 
dishes  are  preferred,  and  in  a  small  number  of  the  cases  there 
is  disgust  for  meat.  The  other  symptoms  commonly  ascribed 
to  chronic  asthenic  gastritis  are  due  to  complications. 

On  awakening  in  the  morning  there  may  be  nausea,  and 
a  small  quantity  of  mucus  and  bile  and  saliva  may  be  vom- 
ited. After  the  meals  the  stomach  feels  full  and  heavy, 
and  there  may  be  nausea  and,  very  seldom,  vomiting.  The 
vomit  is  thick,  ropy,  contains  no  free,  but  possibly  a  little 
combined,  HCl,  and  unchanged  food.  The  digestive  discom- 
fort is,  with  only  a  few  exceptions,  worse  after  meals  of  solid 
food,  liquids  being  well  borne.  There  is  often  repeated 
belching  of  swallowed  air,  bringing  with   it   sometimes   into 


406  DISEASES  OF  THE  STOMACH. 

the  inoutli  a  little  non-acid  fluid.  Throughout  the  day,  and 
particularly  during  the  period  of  gastric  digestion,  the  patient 
feels  vaguely  uncomfortable,  and  indisposed  to  mental  or 
physical  work. 

The  failure  of  digestive  compensation  occurs  early  among 
the  poor,  on  account  of  tli€  coarseness  and  the  bad  quality  of 
their  food.  The  stomach,  with  its  diminished  acidity,  or  even 
neutral  or  alkaline  contents,  is  no  longer  a  barrier  against  the 
invasion  of  the  intestines  by  germs.  Those  who  obtain  fresh 
and  nutritious  food,  and  protect  the  intestines  by  cleanliness, 
— pure  food,  pure  drinks,  sweet  mouth  and  throat, — may  live 
a  long  period  with  nutrition  perfectly  preserved.  Whenever 
malnutrition  exists  in  chronic  asthenic  gastritis,  the  cause 
should  be  sought  for  in  the  alimentation  or  in  the  intes- 
tines. 

Many  of  the  symptoms  attributed  to  asthenic  gastritis  are 
due  to  complicating  intestinal  trouble.  Many  of  the  so- 
called  gastric  refle.x  disorders  of  the  heart  and  of  the  capil- 
lary circulation  have  their  origin  in  the  intestines.  The  flatu- 
lency, often  so  great  as  to  force  the  patient  to  unloosen  the 
clothing,  is  in  the  intestines  and  not  in  the  stomach,  which  is 
pushed  up  and  compressed  by  the  distended  transverse  colon. 
The  belching  of  the  swallowed  air  relieves  the  increased 
abdominal  tension,  but  the  stomach  is  perfectly  free  from  fer- 
mentation and  its  products. 

The  course  of  chronic  asthenic  gastritis  is  very  slow  ;  at 
first  intermittent,  with  periods  of  good  health  and  comfort ; 
it  then  becomes  more  continuous,  and  more  rapidly  progres- 
sive as  intestinal  compensation  fails.  Malnutrition  now 
begins,  the  muscular  layer  becomes  involved  in  the  inflam- 
mation or  undergoes  fatty  degeneration,  the  mucosa  has 
been  converted  into  an  infiltrated  layer  without  peptic  glands, 
and  the  atrophied,  flabby  stomach  may  be  the  seat  of  severe 
lancinating  pains.  Often,  however,  these  pains,  which  are 
most  common  during  the  period  of  gastric  repose,  are  located 
in  the  colon,  the  stomach  being  sweet  and  empty. 

Symptomatology. — The  physical  signs  of  chronic  asthenic 
or  catarrhal'gastritis  possess  chiefly  a  negative  value — no 
tumor,  no  abnormal  splashing,  normal  in  size  and  position, 
but  usually  sensitive  to  pressure. 

The  functional  signs  are  very  important  in  the  diagnosis, 
the  prognosis,  and  the  treatment  of  the  disease.  The  secretion 
is  characterized  first  by  diminution  and  then  by  disappearance 
of  the  free  and  the  combined  HCl,  by  diminution  and  disap- 
pearance of  the  ferments,  and  by  persistent  excess  of  mucus. 


GASTRITIS.  407 

The  terminal  atrophy  is  never  so  complete  as  to  give  no  se- 
cretion ;  but  there  is  a  small  quantity  of  fluid  containing 
mucus,  no  acid,  and  no  traces  of  the  mother  substances  of  the 
ferments.  After  a  test-breakfast,  during  the  pre-atrophic 
stage,  less  than  the  normal  quantity  of  contents  is  obtained, 
thick  and  ropy,  and  of  high  specific  gravity;  the  bread  is  for 
the  most  part  unchanged  ;  occasionally  the  mucus  is  tinged 
with  blood.  There  is  always  less  fluid  in  the  contents  than 
normal,  for  secretion  (except  mucus)  is  less  in  quantity,  and 
the  motor  function  is  active.  There  are  no  organic  acids,  or 
mere  traces  (except  where  butyric  fermentation  is  active  but 
transient  and  accidental),  no  free  HCl,  and  combined  HCl  may 
also  be  completely  absent,  and  the  reaction  of  the  contents 
may  be  neutral,  or  even  alkaline.  The  small  quantity  of  HCl 
secreted  is  combined  with  inorganic  bases,  or  is  neutralized 
by  the  alkaline  exudate  from  the  blood-vessels.  The  acidu- 
lated tube  digestions  show  in  the  beginning  diminution  of  the 
pepsin,  and  the  labferment  and  the  labzymogen  are  also  less 
active  than  in  the  normal  contents.  The  ferments,  however, 
may  not  be  so  deficient  as  we  should  expect  from  the  very 
small  free  hydrochloric  acidity,  and  they  show  the  destruction 
or  degeneration  of  the  peptic  glands  with  greater  exactness 
than  does  the  acid  secretion.  There  is  no  excessive  or  char- 
acteristic germ  growth,  and  the  tube  fermentation  tests  are 
negative.  After  the  test-meal  of  Germain  See,  less  than  the 
normal  quantity  of  contents  is  obtained,  the  food  being  but 
slightly  changed.  There  is  no  peptone,  and  the  propeptones 
and  syntonin  are  present  in  very  small  quantity.  The  tests  for 
achroodextrin  and  for  maltose  are  positive,  ptyalin  digestion 
being  active.  The  contents  are  thick,  for  there  is  less  than 
the  normal  quantity  of  fluid  in  the  stomach.  The  secretory 
signs  display  the  pathological  changes  in  the  mucosa.  The 
excessive  secretion  of  mucus  is  persistent.  The  free  HCl 
diminishes  and  disappears,  and  the  diminution  of  combined 
HCl  becomes  greater  and  finally  disappears.  The  pepsin 
diminishes  in  proportion  to  the  total  hydrochloric  acid 
(H  +  C).  But  before  the  chief  cells  are  degenerate,  the  acid' 
secretion — and  with  it  the  secretion  of  the  ferments — may  be 
improved  by  soothing  medication  to  control  the  secretion  of 
mucus  and  to  relieve  the  subacute  interstitial  gastritis.  The 
improvement  is  in  inverse  proportion  to  the  degeneration 
and  destruction  of  the  peptic  glands.  But  mucus  is  actively 
secreted  even  after  the  peptic  glands  have  been  transformed 
or  destroyed. 

The  motor  function  is  intact,  the  stomach  emptying  itself 


408  DISEASES  OE  THE  STOMACH. 

in  the  normal  time.  Expression  is  easy,  unless  the  contents 
are  very  coarse  or  thick;  it  is  never  difficult  for  the  same 
reason  that  it  is  difficult  in  myasthenia — viz.,  the  unretracted, 
flabby  condition  of  the  stomach.  There  is  no  serious  dis- 
ease of  the  stomach  in  which  the  germ  growth  is  less  tlian 
in  chronic  asthenic  gastritis.  But  butyric  fermentation  occurs 
intermittently  in  a  majority  of  the  cases.  In  the  morning, 
fasting,  the  stomach  is  empty,  or  contains  a  small  quantity  of 
mucus  and  saliva.  The  sediment  of  the  morning  contents 
contains  a  large  quantity  of  single  and  of  exfoliated  masses 
of  cylindrical  cells  and  leukocytes,  mixed  with  mucus.  Ab- 
sorption is  diminished  in  proportion  to  the  diminution  of 
secretion.  The  functional  signs  are  constant  and  do  not 
rapidly  change,  either  spontaneously  or  under  the  influence 
of  diet  or  remedies,  except  in  the  manner  and  for  the  reasons 
already  stated. 

The  urine  presents  no  characteristic  change,  but  the  diges- 
tive fall  in  acidity  is  less  marked  than  in  health,  and  the 
acidity  of  the  twenty-four  hours'  urine  is  high,  and  there  is 
often  a  deposit  of  urates  and  of  uric  acid.  In  the  production 
of  these  changes  the  intestines  often  play  as  important  a 
part  as  does  the  stomach. 

Prognosis. — Chronic  asthenic  or  catarrhal  gastritis  is  a 
serious  disease  which  may  be  arrested  by  proper  treatment, 
and  may  be  completely  compensated  by  healthy  intestines. 
Consequently,  the  prognosis  is  dependent  largely  upon  the 
condition  of  the  intestines  and  upon  the  ability  of  the  patient 
to  obtain  the  proper  food.  It  is  always  more  serious  in 
malarial  and  warm  regions,  on  account  of  the  frequency  of 
hepatic  and  intestinal  diseases.  A  perfect  cure  is  possible 
even  after  degeneration  of  the  peptic  glands  has  begun. 
But  the  greater  the  proliferation  of  the  cylindrical  cells,  the 
greater  the  degeneration  of  the  peptic  cells,  the  greater 
the  number  of  beaker  and  of  ciliated  cells,  the  greater  the 
mucous  transformation,  the  greater  the  diminution  of  the 
total  hydrochloric  acid,  of  the  ferments,  and  of  the  quantity  of 
secretion — ^just  so  much  less  will  be  the  probability  of  the 
restoration  of  normal  secretion.  The  e.xamination  of  a  piece 
of  the  mucous  membrane  is  an  important  aid  alike  in  diag- 
nosis and  prognosis.  But  too  much  weight  should  not  be 
given  to  this  kind  of  information,  for  the  gastritis  may  not  be 
general,  nor  in  the  same  stage  in  all  parts  of  the  stomach. 

Asthenic  gastritis  may  also  be  complicated  by  motor  insuf- 
ficiency, but  this  complication  is  rare  and  occurs  late,  when 
the  muscular  layer  becomes  infiltrated.    The  terminal  period, 


GASTRITIS.  409 

with  inanition  and  gastro-intestinal  atrophy,  is  often  accom- 
panied by  pernicious  anemia. 

Differential  Diagnosis. — Chronic  catarrhal  or  asthenic 
gastritis  is  liable  to  be  mistaken  for  adenasthenia  gastrica, 
neurasthenia  gastrica,  myasthenia  gastrica,  and  carcinoma. 

In  a  general  manner  the  dynamic  affections  are  excluded 
by  the  gastric  symptoms  of  asthenic  gastritis  being  so  closely 
related  to  the  digestive  period  and  to  the  taking  of  food,  and 
being  excited  also  by  solid  food,  particularly  meats,  much 
more  than  by  fluids.  In  gastritis  the  symptoms  are  more 
closely  connected  with  the  alimentation  ;  in  the  dynamic 
afifections  they  are  more  intimately  connected  with  the  state 
of  the  nervous  system.  In  gastritis  the  functional  signs  are 
constant :  in  the  dynamic  affections  the  functional  signs  may 
be  normal,  or,  if  pathological,  they  may  vary  from  day  to  day 
under  petty  and  seemingly  inadequate  influences.  Gastritis 
is  most  frequent  after,  and  the  dynamic  affections  before,  the 
thirtieth  year. 

In  adenasthenia  gastrica  nausea  and  vomiting  do  not  occur. 
There  may  be  diminution  and  even  absence  of  HCl,  but 
there  is  no  excess  of  mucus,  nor  active  epithelial  exfoliation, 
nor  traces  of  blood  in  the  contents  ;  and  the  ferments,  though 
often  are  not  always  continuously  diminished.  The  func- 
tional disorder  often  begins  suddenly,  after  shock,  injury,  or 
moral  depression  ;  chronic  gastritis  develops  slowly,  or  fol- 
lows the  acute  disease.  In  adenasthenia  the  diet  is  without 
influence  on  the  slight  local  discomfort;  in  asthenic  gastritis 
the  local  symptoms  are  made  worse  by  an  improper  diet. 
The  treatment  suitable  to  adenasthenia  is  without  benefit  in 
asthenic  gastritis,  which  demands  a  special  diet  and  local 
remedies  much  less  excitant. 

In  neurasthenia  gastrica  the  abdominal  symptoms  are  di- 
gestive, and  are  excited  by  the  simple  activity  of  the  stomach, 
somewhat  regardless  of  the  quality  of  the  diet.  One  article 
of  food  is  digested  little  better  or  worse  than  another.  In 
neurasthenia  gastrica  the  patient  is  "  dyspeptic  "  because  he 
suffers  and  complains,  there  being  no  marked  and  constant 
chemical  insufificiency.  The  secretory  signs  are  in  vivid  con- 
trast with  the  hypochlorhydria,  excess  of  mucus,  and  con- 
stant diminution  of  the  ferments  found  in  asthenic   gastritis. 

In  myasthenia  gastrica  the  signs  of  the  motor  insufficiency 
at  once  make  the  differentiation,  except  in  the  rare  cases 
where  motor  insufificiency  is  a  complication  of  the  asthenic 
gastritis.  Fluids  are  worse  borne  than  a  dry  solid  meal,  the 
contrary  being  true  in  gastritis.    The  chemical  signs  of  myas- 


410  DISEASES  OF  THE  STOMACH. 

thenia — secretion  being  rarely  constantly  diminished — are  in 
contrast  with  those  of  i^astritis.  But  asthenic  gastritis  may 
develop  as  a  complication  of  myasthenia  ;  and,  apart  from  the 
presumption  being  in  favor  of  the  myasthenia  as  the  primary 
trouble  when  the  two  diseases  are  found  associated,  only  a 
knowletlge  of  the  development  of  the  case  could  clear  up 
the  difficulty. 

There  is  little  chance  of  confounding  gastritis  with  carci- 
noma, if  the  case  has  been  well  studied.  The  secretory  signs 
in  the  two  diseases  may  be  alike,  for  in  both  they  are  pro- 
duced by  catarrhal  or  asthenic  gastritis  ;  but  there  the  resem- 
blance ends.  There  may  be  motor  insufficiency  in  carcinoma, 
and  this  occurs  late  (terminal  period)  in  asthenic  gastritis. 
Not  one  sign,  but  the  two  groups  of  signs,  in  the  two  dis- 
eases, should  furnish  the  reasons  for  the  decision.  For  the 
differential  diagnosis,  see  the  chapter  on  Carcinoma. 

Treatment. — It  is  much  easier  to  prevent  chronic  gastritis 
than  to  arrest  the  disease  when  it  is  fully  developed.  For 
this  reason  the  functional  disorders  of  the  stomach  should 
receive  careful  treatment,  and  the  stomach  should  be  guarded 
and  favored  in  all  diseases  of  other  organs  which  play  a  part 
in  the  causation  of  gastritis.  The  prophylaxis  consists  in 
strict  digestive  hygiene,  a  proper  diet,  and,  what  is  more 
often  disregarded,  but  is  equally  important,  in  the  avoidance 
of  all  drugs  which  disturb  its  functions  and  injure  the 
mucous  membrane.  Dietetic  abuses  have  become  so  firmly 
fi.xed  in  the  customs  and  habits  of  the  people  that  there  is 
little  danger  of  the  disease  disappearing,  or  of  its  becoming 
easy  to  find  a  healthy  stomach  more  than  forty  years  old. 
15ut  probably  some  good  may  be  done  by  recommending,  to 
tiiose  who  most  need  the  advice,  temperance  in  eating  and 
drinking,  and  by  correcting  gross  violations  of  digestive 
hygiene. 

The  treatment  of  secondary  gastritis  is  in  part  the  proper 
treatment  of  the  disease  which  caused  it.  The  management 
of  the  disease  of  the  stomach  is  modified  by  the  necessity  of 
controlling  or  of  removing  its  cause.  This  subject  is  dis- 
cussed in  the  section  on  the  Vicious  Circles  of  the  Stomach. 

The  most  important  indications  to  be  met  by  the  treatment 
of  chronic  asthenic  gastritis  are:(i)  To  protect  and  to  favor 
the  inflamed  organ  ;  (2)  to  maintain  intestinal  compensation; 
(3)  to  excite  the  deficient  secretion  of  the  stomach  by  physio- 
logical remedies;  (4)  to  remove  the  excess  of  mucus  when  it 
is  thought  best  to  do  so  ;  (5)  to  treat  gross  symptoms  and 
complications. 


GASTRITIS.  411 

The  most  valuable  principle  of  affording  the  greatest  possi- 
ble protection  to  a  diseased  organ  should  guide  us  in  the 
treatment  of  the  anatomical  diseases  of  the  stomach.  The 
proper  treatment  of  chronic  gastritis  is  an  embodiment  of 
protection  and  of  favoritism.  A  great  deal  of  injury  can  be 
done  by  trying  to  force  the  stomach  to  do  its  full  chemical 
work,  and  by  filling  the  organs  with  antifermentatives  and 
antiseptics  to  drive  out  an  imaginary  evil. 

A  diet  properly  regulated  is  our  most  important  remedy  in 
asthenic  gastritis,  and  is  often  capable  alone  of  suppressing 
the  symptoms  and  of  arresting  or  curing  the  gastritis.  The 
chemical  work  of  the  stomach  being  very  much  reduced  on 
account  of  the  diminished  secretion,  the  disintegrating  and 
solvent  work  of  the  gastric  juice  should  be  as  far  as  possible 
done  by  the  preparation  and  the  thorough  mastication  of  the 
food.  The  motor  power  of  the  stomach  must  be  carefully 
nursed  and  guarded,  for  the  maintenance  of  the  balance  of 
nutrition  depends  on  the  delivery  to  the  intestines  of  food 
in  sufficient  quantity,  and  capable  of  digestion  and  utiliization 
by  the  part  of  the  digestive  tube  below  the  pylorus.  The 
disease  is  in  the  stomach,  but  the  intestines  have  the  most 
to  do  with  the  selection  of  the  diet. 

Before  and  after  each  meal  the  mouth  and  the  teeth  should 
be  cleaned,  and  all  the  food  eaten  should  be  perfectly  fresh. 
The  intestines  being  no  longer  protected  by  the  acid  gastric 
secretion  against  bacterial  invasion,  every  precaution  should 
be  taken  to  have  the  food  pure  and  sweet. 

The  gastric  acidity  is  not  sufficient  to  arrest  the  action  of 
the  ptyalin,  and  the  starches  should  be  most  thoroughly 
chewed  and  insalivated,  and  the  work  of  the  intestines  thus 
made  lighter. 

Physical  and  chemical  irritants  should  be  excluded  from  the 
diet.  Alcohol  is  particularly  injurious,  irritating  the  inflamed 
mucous  membrane,  by  which  it  is  not  actively  absorbed  as  in 
health,  and  a  large  part  of  it  is  consequently  conveyed  into 
the  intestines.  The  food  should  contain  only  a  moderate 
quantity  of  salt,  and  should  never  be  highly  seasoned.  A 
small  quantity  of  mild  sauce  may  be  used  to  appeal  to  the 
palate.  Fat  in  excess,  as  demonstrated  by  Leven,  is  also  a 
gastric  irritant,  and  diminishes  motor  activity.  More  than 
a  very  small  quantity  of  cane-sugar  must  be  prohibited,  as  an 
intestinal  prophylactic  measure.  Milk-sugar  is  not  objection- 
able if  the  small  intestine  is  healthy.  But  all  forms  of  sugar 
are  hydragogue,  and  in  excess  and  in  concentrated  solutions 
are  irritant,  and  unless  rapidly  absorbed  are  liable  to  ferment  in 


412  DISEASES  OF  THE  STOMACH. 

the  intestines.  It  is  a  rule  established  by  clinical  experi- 
ence that  sweets  and  fats  must  be  reduced  to  a  minimum  in 
the  treatment  of  asthenic  gastritis,  but  moderate  quantities  of 
fresh  butter  should  always  be  given,  and  are  usually  well 
borne. 

The  sweets  may  be  partly  replaced  by  gelatinous  foods, 
which  possess  a  high  force  value,  resist  fermentation,  and  are 
rapidly  digested  and  utilized  by  the  intestines.  Calf's-  and 
pig's-foot  jelly  and  calf's  head  (milk  sauce)  may  be  utilized 
for  maintaining  nutrition. 

The  albuminous  foods  escape  gastric  digestion,  but  this 
affords  no  reason  for  diminishing  the  quantity  of  this  class  of 
food.  But  the  quality  and  the  preparation  must  be  favorable 
to  intestinal  digestion  and  utilization.  The  meats  should  be 
tender,  lean,  finely  divided  (chopped  or  scraped),  and  as 
free  as  possible  from  indigestible  tissue  (skin,  tendon,  blood- 
vessels, fascia).  No  fried  or  greasy  dishes  should  be  per- 
mitted, and  all  the  meats,  poultry,  and  game  should  be  either 
stewed,  broiled,  or  grilled. 

Milk  is  well  borne  in  some  cases,  and  should  then  be  per- 
mitted as  a  drink  and  in  the  preparation  of  vegetables,  sauces, 
with  cereals,  etc.  It  should  never  be  given  in  the  exceptional 
cases  with  gastric  fermentation,  nor  where  there  is  stagnation 
in  the  small  intestine;  on  the  appearance  of  the  first  signs 
of  gastric  or  intestinal  fermentation  it  should  be  immediately 
excluded. 

Not  more  than  one  glass  of  fluid  should  be  allowed  with 
a  meal.  The  starch-containing  foods  should  be  thoroughly 
masticated  and  insalivated  before  being  washed  down  with 
water  or  swallowed.  No  alcoholic  drinks  should  be  per- 
mitted. Plain  water  and  very  weak  tea  are  the  most  suitable 
drinks  ;  chocolate  and  cocoa  are  better  borne  than  coffee,  and 
in  e.xceptional  cases  may  be  permitted,  particularly  Haus- 
waldt's  "  vigor  chocolate." 

The  following  articles  should  form  the  staple  foods,  and 
should  be  given  in  combination  and  quantity  in  keeping 
with  the  principles  of  dietetics,  so  as  not  only  to  maintain, 
but,  if  need  be,  to  improve  nutrition.  But  where  a  trouble 
of  the  intestines  is  associated  with  the  gastritis,  it  may  be 
necessary  to  restrict  and  to  lower  the  diet  temporarily  below 
the  requirements  of  nutrition  until  the  intestinal  disease  is 
under  control  and  digestive  compensation  is  reestablished. 
All  tender  lean  meats,  beef,  mutton,  calf's-brain,  sweet- 
bread, young  chicken,  squab,  animal  jellies,  lean  and  fine- 
meated  fish,  soft    part    of  oysters  in  season,  whites   of  eggs 


GASTRITIS.  413 

cooked  just  enough  to  hold  together,  and  the  yolks  of  eggs 
(when  there  is  no  intestinal  putrefaction),  and  milk,  when  well 
borne  (which  is  not  the  case  if  there  is  intestinal  fermenta- 
tion); preparations  of  rice  and  wheat,  thoroughly  cooked, 
spinach  passed  through  a  sieve,  cooked  tender  sprigs  of 
celery,  mashed  French  peas,  tender  string  beans  passed 
through  a  colander,  and  tender  sprigs  of  lettuce  with  a  little 
salt,  white  bread  toasted  through  and  through,  or  the  crust 
of  roll;  and  in  some  cases  thoroughly  cooked  mashed  pota- 
toes or  a  mealy  boiled  potato  may  be  permitted. 

All  other  articles  are  prohibited  until  the  disease  is  arrested, 
as  indicated  by  the  functional  signs,  and  until  digestive  com- 
pensation is  well  established.  But  the  deficient  chemical  work 
of  the  stomach  will  necessitate  the  observance  of  hygiene, 
and  the  continuance  of  a  diet  favoring  and  nursing  the  motor 
power  of  the  stomach,  and  maintaining  strict  intestinal  pro- 
phylaxis. It  may  be  necessary  to  prescribe  a  fluid  diet  for  a 
short  time,  to  give  four  or  five  small  meals  a  day,  and  to  per- 
mit only  such  foods  as  are  evacuated  by  the  normal  stomach 
in  about  three  hours.  Select,  in  the  beginning  of  treat- 
ment, such  foods  as  leave  the  stomach  rapidly,  such  as  have 
little  action  on  its  mucous  membrane,  and  such  as  are  utilized 
by  the  intestines  in  sufficient  quantity  to  support  or  to  improve 
nutrition. 

This  is  the  rule  when  it  is  necessary  to  protect  and  favor 
the  stomach  ;  but  such  is  not  always  the  proper  course.  The 
diet  may  be  used  as  a  physiological  remedy  to  excite  secre- 
tion when  excitation  is  desirable.  The  meats  are  strong  ex- 
citants of  secretion  ;  the  green  vegetables,  fruits,  and  sweets 
act  in  a  similar  manner  ;  and  peptones  and  albumoses  may  be 
prescribed  for  the  same  purpose,  and  condiments  may  be  per- 
mitted in  moderation.  It  is  better  to  use  food  as  an  excitant 
remedy  than  to  prescribe  drugs  for  the  same  purpose;  but 
the  intragastric  douche  with  a  physiological  salt  solution  is  a 
valuable  synergist. 

The  bowels  should  be  kept  regulated  by  massage,  elec- 
tricity, and  injections  to  which  glycerin  may  be  added.  If 
intestinal  fermentation  becomes  active,  a  dose  of  calomel 
should  occasionally  be  given. 

The  appetite  may  be  so  diminished  as  to  require  special 
treatment,  the  increase  of  the  appetite  improving  also  the 
psychic  state  of  the  patient.  An  infusion  of  condurango  or 
calumba  may  be  given  with  a  tablet  of  strychnin. 

The  general  restorative  and  hygienic  remedies — physio- 
logical   living,    hydrotherapy,    electricity,    etc. — should    not 


414  DISEASES  OF  THE  STOMACH. 

be  neglected,  and  every  means  should  be  used  to  maintain 
and  to  impio\e  nutrition,  to  tone  and  to  rest  the  nervous 
system,  to  protect  and  to  favor  the  stomach,  and  to  secure 
digestive  compensation  by  the  intestines.  Stomach  wash- 
ing may  be  employed  to  remove  the  very  large  quantity 
of  mucus,  but  we  rarely  employ  it  in  asthenic  gastritis 
unless  there  is  butyric  fermentation.  Lavage  should  be  done 
at  bedtime  or  in  the  morning  before  breakfast,  using  plain 
warm  water,  or  a  little  lime-water  (i  to  lo)  may  be  added.  If 
the  patient  is  not  accustomed  to  the  tube,  a  glass  of  hot  water 
maybe  slowly  sipped  an  hour  before  breakfast.  The  addition 
of  a  few  grains  of  sodium  chlorid  and  calcium  chlorid  to  the 
hot  water  usually  controls  the  butyric  fermentation.  We 
rarely  prescribe  mineral  waters  and  so-called  mucus-solvents 
in  asthenic  gastritis.  Indeed,  the  good  motor  function  and 
the  traversing  food  and  water,  aided,  if  need  be,  by  lavage,  are 
sufficient  to  remove  the  excess  of  mucus  ;  and  it  would  seem 
wise  to  leave  enough  sweet  mucus  on  the  surface  of  the  stom- 
ach to  protect  the  mucosa.  The  long  preservation  of  the  glan- 
dular division  of  the  mucosa  in  health  and  repose  is  due  to  the 
non-injurious  and  protecting  coat  of  thick  mucus.  Some  aid 
may  be  rendered  the  intestines  in  their  digestive  work  by  sup- 
plementary chemical  treatment,  using  hydrochloric  acid,  and, 
in  the  advanced  stage  of  the  destructive  process,  also  pepsin, 
or  papoid  alone.  When  the  In-drochloric  acid  is  used  as  a  di- 
gestive agent,  two  doses  of  the  dilute  acid  (about  20  drops) 
should  be  given  during  the  functional  activity  of  the  stomach, 
about  si.xty  and  ninety  minutes  after  the  beginning  of  the  meal. 
Pepsin  should  always  be  combined  with  it.  In  the  few  cases 
with  gastric  fermentation,  a  dose  of  the  acid  may  be  given  as 
an  antizymotic,  half  an  hour  before  each  meal.  Papoid  may 
be  employed  without  the  acid  when  the  stomach  is  atrophied 
or  when  a  complicating  nephritis  exists.  But  supplementary 
chemical  aid  should  never  be  employed  until  the  period  has 
arrived  for  excitant  treatment,  for,  while  it  may  aid  the  intes- 
tines, it  may  injure  the  stomach. 


II.  GASTRITIS   GLANDULARIS    PROLIFERANS,    OR    CHRONIC 
HYPERSTHENIC  GASTRITIS. 

Pathological  Anatomy. — In  chronic  asthenic  gastritis  the 
cylindrical  cells  which  cover  the  surface  of  the  mucous  mem- 
brane and  line  the  mucous  ends  of  the  ducts  of  the  glands 
proliferate,  and  may  replace  the  degenerate  chief  and  border 


GASTRITIS. 


415 


cells,  thus  converting  many  of  the  peptic  into  mucous  glands. 
Or  the  fundus  of  the  degenerate  gland  disappears  and  noth- 
ing is  left  but  the  elongated  duct  of  the  gland,  lined  with 
cylindrical  cells,  with  beaker  cells,  and  with  ciliated  columnar 
epithelium.  In  this  process  the  proliferation  and  infiltration  of 
the  connective  tissue  may  play  a  more  or  less  important  part. 
In  chronic  proliferating  glandular  gastritis  the  pathological 
process  is  different  and  in  bold  contrast.  There  may  be  the 
same  infiltration  and  proliferation  of  the  connective  tissue,  and 


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Fig.  22. — Gastritis  glandularis  prolifcrans.     X  240.     (Authors'  specimen.) 


the  same  wandering  of  leukocytes,  which  are,  as  a  rule,  oxy- 
phile.  But  the  proliferation  affects  the  cells  of  the  peptic 
glands  ;  the  cylindrical  mucus-secreting  cells  remain  n'formal,  or 
degenerate  and  disappear  over  large  areas  of  the  surface  of 
the  mucous  mfembrane,  and  many  of  the  pyloric  glands  be- 
come lined  with  cells  resembling  the  chief  and  border  cells  of 
the  peptic  glands  (Fig.  22). 

The  mucous  membrane  is  covered  with  mucus,  which  is 
stained  with  blood  and  is  ordinarily  thin  and  mixed  with  the 
nuclei  of  partly  digested  cells.     The   surface   of  the  mucous 


41 6  DISEASES  OE  THE  STOMACH. 

membrane  is  very  vulnerable  ;  it  is  not,  orciinarily,  niammel- 
lated,  but  the  little  villosities  may  be  jirominent,  and  the 
mucous  membrane  is  firm  and  thick.  Large  areas  of  the 
mucous  membrane  are  denuded  of  epithelium,  and  a  peptic 
(round)  ulcer  is  not  rare.  The  surface  epithelium  is  usually 
destroyed  by  postmortem  digestion,  but  it  may  be  found 
well  preserved  in  small  pieces  of  the  mucous  membrane  ob- 
tained through  the  tube;  there  are  no  beaker  cells,  no  re- 
verted ciliated  columnar  epithelia,  no  mucoid  degeneration 
of  the  cylindrical  cells,  but  rarely  a  very  ievj  cylindrical  cells 
may  show  mitosis  (normal).  In  old  cases  the  superficial 
layer  of  the  mucosa  may  be  richly  infiltrated,  and  the  nutri- 
tion of  the  surface  epithelia  may  be  cut  off  and  their  reproduc- 
tion arrested.  The  positive  characteristic  of  the  gastritis  is 
the  proliferation  of  the  border  and  the  chief  cells.  Some  cases 
show  few  border  cells,  and  some  few  chief  cells,  and  the  pre- 
dominance of  the  one  or  the  other  cell  may  depend  on  the 
functional  state  of  the  gland  when  the  specimen  is  obtained — 
in  the  morning,  when  the  stomach  is  in  repose  and  has  been 
empty  for  some  time,  or  during  digestion,  or  during  the  period 
when  the  stomach  still  has  stagnant  or  retained  food  in  it. 
But  the  glands  are  ordinarily  in  a  state  of  functional  activity, 
and  the  chief  cells  greatly  diminish  in  number.  It  is  possible 
that  autodigestion  and  their  normally  low  vitality  have  some- 
thing to  do  with  their  disappearance.  Under  the  microscope 
the  glands  appear  lined  with  cells  which  are  well  preserved 
and  closely  packed,  and  some  of  the  younger  ones  stain  in- 
tensely. The  lumen  of  the  glands  is  filled  with  granular  mat- 
ter, a  few  leukocytes,  and  the  remains  of  chief  cells.  Many 
of  the  cells  contain  more  than  one  nucleus.  The  swelling  of 
the  mucosa  is  due  to  the  active  proliferation  of  connective  tis- 
sue in  the  first  anatomical  stage  of  many  cases,  but  the  inflam- 
mation may  be  interstitial  in  the  beginning,  or  the  interstitial 
inflammation  may  develop  in  the  course  of  the  evolution  of 
the  case.  Proliferating  glandular  gastritis  rarely  ends  in  ana- 
denia  gastrica,  though  many  of  the  glands  may  be  compressed 
and  deformed,  and  even  destroyed,  by  the  interstitial  inflam- 
mation, and  in  old  cases  many  of  the  cells  undergo  granular 
and  mucoid  degeneration  and  vacuolation.  Some  of  the 
pyloric  glands  contain  a  few  border  cells,  and  these  glands,  as 
Hayem  first  discovered,  may  be  converted  into  true  peptic 
glands.  The  rich  and  excessive  secretion  is  the  natural  se- 
quence of  the  pathological  alterations  of  the  glandular  layer. 
Clinical  Description. — The  symptoms  of  hypersthenic  or 
proliferating  glandular  gastritis  may  be  confined  to  the  nor 


GASTJUTIS.  417 

mal  digestive  period,  and  they  cease  entirely  after  the  stom- 
ach has  emptied  itself  unless  secretion  is  continuous.  Like 
chronic  asthenic  gastritis,  the  disease  may  be  perfectly  latent 
for  a  long  period  ;  or  it  may  manifest  itself  by  distant,  and 
not  by  local,  subjective  symptoms. 

The  appetite  is  good,  and  often  greatly  increased,  but  there 
is  no  selective  desire  for  spicy  articles  or  for  sour  food.  Soon 
after  the  meal  the  stomach  may  feel  full,  and  there  is  for  a 
short  time  a  sense  of  well-being;  but  as  digestion  proceeds, 
heartburn,  eructations,  and  pain  begin.  Thirst  is  usually 
strong,  and  the  pain  and  the  burning  are  relieved  by  drink- 
ing water.  There  is  no  nausea  and  no  vomiting.  The  local 
pain  increases  with  the  evolution  of  digestion,  but  is  relieved 
by  fluids,  albuminous  foods,  and  alkalies.  The  intensity  of 
the  symptoms  is  proportionate  to  the  physiological  action  of 
the  food  on  secretion,  to  the  state  of  the  nervous  system,  to 
the  activity  and  richness  of  secretion,  and  to  the  time  during 
which  it  remains  undigested  in  the  stomach.  Starches,  sweets, 
and  fats  are  not  so  well  borne  as  is  albuminous  food,  and  a 
glass  of  milk  may  be  digested  with  but  little  discomfort. 
This  is  the  simplest  and  the  mildest  type  of  chronic  hyper- 
sthenic gastritis,  which  may  have  begun  suddenly  with  an 
attack  of  acute  gastritis,  or  have  been  preceded,  for  a  variable 
period  of  a  few  months  or  years,  by  adenohypersthenia,  or 
which  may  have  long  remained  latent  or  manifested  itself 
intermittently  by  subjective  symptoms. 

Where  acetic  or  butyric  fermentation  is  associated  with 
the  glandular  gastritis  and  morbid  sensibility,  the  preceding 
symptoms  are  intensified  ;  and  during  the  period  when,  nor- 
mally, digestion  would  be  in  the  stage  of  decline,  the  pain 
may  become  paroxysmal,  and  radiate  from  the  stomach  over 
the  abdomen  and  into  the  back.  The  symptoms  are  incom- 
pletely relieved  by  water,  by  albuminous  foods,  and  by  alkalies. 
There  is  often  headache  and  nausea,  which  may  terminate  with 
vomiting.  But  the  symptoms  maintain  the  same  relation  to 
the  evolution  of  digestion,  and  to  the  quantity  and  composi- 
tion of  the  diet,  as  in  the  simple  form. 

In  other  cases  the  symptoms  are  not  confined  to  the  nor- 
mal digestive  period,  but  encroach  upon  the  period  of  gastric 
repose.  The  local  symptoms  then  become  more  continuous, 
with  digestive  exacerbations,  and  with  nocturnal  attacks  of 
pain  and  nausea,  and  sometimes  vomiting.  The  glandular  gas- 
tritis is  complicated  with  prolonged  digestion  produced  by 
supersecretion.  Stagnation  may  end  in  retention,  and  the 
stomach  may  never  completely  evacuate  through  the  pylorus 
27 


4l8  DISEASES  OE  THE  STOMACH. 

the  food  taken  into  it;  or  secretion  may  become  continuous, 
and  the  organ  never  get  rest  from  irritation. 

The  simple  type  with  digestive  symptoms,  at  any  moment, 
through  dietetic  errors  or  through  fatigue,  may  become 
marked  by  periods  when  fermentation  is  active ;  or  stagna- 
tion or  retention  may  occur  for  a  few  days.  The  progress  of 
the  disease  is  then  characterized  by  periods  during  which  all 
the  symptoms  are  exaggerated  and  accompanied  by  nausea  and 
vomiting,  lasting  a  number  of  days;  and  by  periods  lasting  a 
week  or  a  month  or  longer,  during  which  the  patient  is  com- 
paratively comfortable. 

The  emaciation  becomes  greater  and  greater  as  the  suffer- 
ing, the  loss  by  vomiting,  the  destruction  of  food  by  fermenta- 
tion, and  its  waste  in  intestinal  putrefaction  increase.  The 
disease  now  becomes  a  menace  to  life.  Continuous  secretion 
and  retention,  with  fermentation,  excite  more  and  more  the 
inflammation,  which  becomes  more  and  more  interstitial 
and  the  destruction  of  the  glands  and  the  muscular  fibers 
begins.  The  patient,  who  is  generally  a  man  between  twenty 
and  forty,  is  now  emaciated,  sallow,  with  long  suffering  traced 
in  all  his  features.  The  appetite  is  irregular  and  sharp,  and  in 
order  to  satisfy  it  food  is  taken  irregularh^  and  frequently. 
As  the  rule,  the  morning  is  the  most  comfortable  part  of  the 
day,  but  in  the  afternoon  the  accumulated  contents — consist- 
ing of  the  foods  and  fluids  ingested,  the  secretions,  and  the 
products  of  fermentation  and  digestion — may  so  irritate  the 
mucous  membrane  as  to  produce  a  severe  paroxysm  of  pain, 
nausea,  and  vomiting.  The  vomit  consists  of  a  greenish  or  a 
grayish  fluid,  mi.xed  with  undigested  starch,  ropy,  acid,  and 
separating  into  three  layers  on  standing.  The  dinner  is  taken 
with  appetite,  and  from  four  to  si.x  hours  later  a  second  par- 
oxysm, like  that  of  the  afternoon,  may  rob  the  patient  of  all 
but  a  few  hours'  sleep.  There  may  be  only  one  paroxysm 
during  the  twenty-four  hours,  and  the  vomiting  may  be  re- 
placed by  diarrhea.  Ulcer  may  develop  at  any  stage  of  the 
evolution  of  the  disease,  from  the  simple  digestive  form  to  its 
terminal  period — supersecretion,  stagnation,  fermentation,  and 
finally  retention  being  the  intercurrent  episodes. 

The  stage  of  hypersthenic  gastritis  characterized  by  con- 
tinuous secretion  and  motor  insufficiency  constitutes  a  symp- 
tom-group sometimes  described  as  Reichmann's  disease.  The 
same  symptom-group  may  characterize  a  stage  in  the  evolu- 
tion of  myasthenia,  of  gastroptosis,  and  of  pyloric  obstruction. 

Symptomatology. — The  a]:)petite  in  the  hypersthenic  form 
is  well   preserved,  and  although  often  diminished  during  the 


GASTJwns.  419 

paroxysms  of  pain  and  vomiting,  it  is  never  completely  lost, 
as  may  be  the  case  in  anorexia  nervosa,  in  cancer,  and  in 
asthenic  gastritis,  and  in  myasthenia  with  retention  and  fer- 
mentation. On  the  other  hand,  during  the  periods  of  im- 
provement the  appetite  is  unusually  sharp,  and  may  become 
as  imperative  as  in  bulimia.  « 

Thirst  is  also  a  common  symptom,  and  may  become  very 
strong  during  the  height  of  digestion  and  after  profuse  vomit- 
ing and  diarrhea.  The  patient  soon  learns  that  the  pain  is 
moderated  by  drinking  water,  and  in  the  beginning  of  par- 
oxysms may  take  it  in  very  large  quantities. 

Pain  is  a  characteristic  and  frequent  symptom,  and  varies  in 
intensity  and  in  its  qualities  in  the  different  stages.  So  long 
as  the  motor  power  is  normal  and  there  is  no  fermentation 
the  pain  is  digestive,  and  is  most  intense  when  the  quantity  of 
free  hydrochloric  acid  is  greatest.  But  in  this  stage  of  the 
disease,  after  a  small  non-irritating  meal,  it  may  be  replaced 
by  discomfort  and  heartburn.  When  motor  insufficiency 
appears  as  a  complication,  the  pain  recurs  in  paroxysms,  due 
to  the  accumulation  of  the  irritant  contents.  It  is  located  in 
the  epigastrium,  and  radiates  to  the  left  and  over  the  abdo- 
men and  into  the  back,  burning  and  unbearable.  It  is  relieved 
by  albuminous  foods,  such  as  meats,  milk,  and  eggs,  and,  more 
completely,  by  large  doses  of  alkalies.  It  subsides  also  after 
vomiting  (if  complete)  and  lavage  and  after  the  evacua- 
tion of  the  stomach  into  the  duodenum. 

Nutrition  in  the  beginning  is  well  preserved,  but  emaciation 
develops  with  the  increase  of  fermentation,  of  vomiting,  of 
retention,  and  of  disturbance  of  the  functions  of  the  intestines. 
In  the  advanced  stages  it  may  become  extreme,  and  may  be 
associated  with  cachexia  as  pronounced  as  in  cancer. 

The  physical  signs  are  not  characteristic,  and  reveal  a 
complication — such  as  ulcer,  stagnation,  and  retention — more 
often  than  they  reveal  the  gastritis  itself. 

The  functional  and  bacteriological  signs  not  only  aid  in 
making  the  diagnosis,  but  also  indicate  the  stage  which  the 
disease  has  attained  in  its  evolution,  and  are  valuable  guides 
in  the  treatment.  As  regards  the  functional  signs,  the  dis- 
ease may  be  divided  into  three  stages  or  periods:  (i) 
Initial  period  ;  (2)  period  of  prolonged  digestion;  (3)  terminal 
period. 

During  the  initial  period  the  motor  function  is  sufficient,  and 
the  stomach  empties  itself  in  the  normal  time.  The  resting 
stomach  contains  no  remains  of  undigested  food  nor  digestive 
products.     The  tube,  introduced  in  the  morning  before  break- 


420  DISEASES  OE  THE  STOMACH. 

fast,  withdraws  possibly  a  few  cubic  centimeters  of  fluid,  slic^htly 
acid,  and  containing  mucus, and  sometimes  saliva;  the  sediment 
contains  spiral  cells,  nuclei,  sometimes  a  few  wandering  leuko- 
cytes, bacteria,  but  no  yeast  or  sarcinae.  After  the  test-break- 
fast about  the  normal  quantity  of  contents  is  obtained,  gra)ish 
or  greenish,  with  a  peculiar  acid  odor.  The  bread  (except 
starch)  is  well  digested,  but  the  mixture  is  not  so  homogeneous 
as  in  health,  and  contains  an  excess  of  mucus.  There  are  no 
organic  acids.  The  total  hydrochloric  acidity  is  very  high 
(70  to  120),  of  which  part  (C)  is  combined  (10  to  40)  and  part 
(H)  is  free  (20  to  60).  The  tube  digestions  are  very  active, 
the  acidulated  50  per  cent,  dilution  digesting  as  rapidly  as  the 
undiluted  filtrate  in  health.  The  labferment  and  the  lab- 
zymogen  are  both  very  active.  The  contents  obtained  two 
hours  after  the  test-meal  of  Germain  See  contain  nearly  all 
the  meat  in  solution,  only  a  few  fibers  already  undergoing 
disintegration  being  discoverable  with  the  microscope.  Syn- 
tonin  and  propeptones  are  abundant,  and  both  the  biuret  and 
Almen's  reactions  for  peptones  are  plain.  The  starch  is  not 
difjested  as  well  as  in  health,  and  there  is  no  accumulation  of 
pt)'alin  products.  The  tube  fermentations  are  negative,  and 
the  total  quantity  of  the  contents  obtained  after  the  test-meals, 
as  estimated  by  the  method  of  Mathieu  or  of  Strauss,  is  some- 
times normal,  but  is  ordinarily  excessive,  on  account  of  the 
usually  excessive  activity  of  secretion.  The  hydrochloric 
acidity  (H  -\-  C)  is  excessive,  and  the  excess  may  be  due  to  an 
excess  of  both  (H)  and  (C),  or  to  an  excess  of  (H)  chiefly,  or 
of  (C)  chiefly.  The  free  (H)  hydrochloric  acid  may  appear 
too  early  in  the  evolution  of  digestion  (before  thirty  minutes), 
and  the  acme  of  hydrochloric  activity  may  occur  during  the 
second  hour  of  the  digestion  of  the  test-breakfast.  The  line 
which  represents  the  evolution  of  (H  -f-  C)  displays  no  sud- 
den rises  and  falls,  although  it  runs  abnormally  high.  Se- 
cretion ceases  with  the  evacuation  of  the  stomach,  which 
occurs  within  the  normal  time. 

During  the  period  with  prolonged  digestion,  two  conditions 
may  be  found.  In  the  one,  the  signs  are  the  same  as  in  the 
initial  stage,  with  a  few  differences.  The  contents  are  exces- 
sively rich  in  (H  +  C)  hydrochloric  acid  and  the  ferments. 
The  albumin  digestion  is  rapid,  and  starch  digestion  is  dimin- 
ished. The  evolution  of  secretion  is  exi)osed  to  the  same 
disorders.  But  the  quantity  of  the  contents  is  greater  than 
normal,  and  the  excessive  quantity  is  due  to  supersecretion 
or  to  spasm  of  the  pylorus.  The  stomach  contains  remnants 
of  the  roll,  and  products  of  pepsin  digestion.     After  the  acme 


GASTRITIS.  421 

of  digestion  too  much  free  HCl  is  always  found,  and,  as 
digestion  proceeds  toward  its  termination,  the  percentage  of 
free  hydrochloric  acid  increases  and  that  of  the  combined 
hydrochloric  acid  diminishes.  The  stomach  may  contain  some 
of  the  test-breakfast  at  the  end  of  three  hours.  In  the  ordinary 
course  of  events  the  stomach  may  succeed  in  emptying  itself 
between  each  meal,  or  the  digestion  of  one  meal  may  not  be 
completed  when  another  is  begun.  But  when  the  prolon- 
gation of  digestion  is  due  to  supersecretion,  the  stomach  al- 
ways empties  itself  during  the  night  unless  secretion  is  con- 
tinuous. The  stomach  is  empty  one  and  one-half  hours  after 
the  water  test,  or  it  contains  a  variable  quantity  of  se,cretion, 
rich  in  acid  and  ferments.  There  is  no  myasthenia;  diges- 
tion is  prolonged  because  secretion  is  excessive,  and  secretion 
ceases  soon  after  the  stomach  is  empty.  The  second  con- 
dition is  characterized  by  continuous  secretion.  The  signs 
are  nearly  the  same  as  in  the  first  form  with  supersecretion, 
but  the  tube,  introduced  in  the  morning,  before  breakfast, 
withdraws  a  greenish  or  grayish  ropy  fluid,  without  or  with 
alimentary  residue,  varying  from  50  to  250  c.c.  or  more  in 
quantity,  containing  free  hydrochloric  acid  (5  to  20  or  50), 
possibly  a  small  quantity  of  combined  HCl  (digested  cellular 
protoplasm),  digesting  albumin  actively  in  the  tubes,  and  pos- 
sessing a  sp.  gr.  of  1004  to  1006.  About  the  same  quantity 
of  secretion  may  be  obtained  after  the  stomach  has  been 
washed  out  the  previous  evening,  nothing  (food,  water,  nor 
saliva,  etc.)  having  been  ingested  or  swallowed  during  the 
night.  The  glands  continue  to  secrete  throughout  the  twenty- 
four  hours.  In  continuo«s  secretion  the  starches  undergo  no 
change.  There  may  be  slight  fermentation — a  small  quan- 
tity of  organic  acids  in  the  contents,  a  moderate  amount  of 
budding  yeast,  sarcinae,  bacteria,  particularly  cocci,  and,  pos- 
sibly, a  little  gas  formation  in  the  fermentation  tubes. 

Secretion  during  the  terminal  period  may  remain  excessively 
rich  and  be  less  than  normal  in  quantity.  The  evacuation  of 
the  stomach  is  then  abnormally  rapid,  unless  the  motor  func- 
tion is  made  insufficient  by  a  complication.  Or,  again,  the 
hydrochloric  acidity  (H  -\-  C)  may  be  less  than  in  health,  and 
secretion  may  be  about  normal  in  quantity,  or  it  may  be 
excessive,  or  it  may  be  continuous.  Consequently,  digestion 
may  be  finished  too  rapidly,  in  the  normal  time,  or  it  may  be 
prolonged.  But  the  prolongation  is  the  result  of  the  exces- 
sive secretion  and  is  not  due  to  motor  insufficiency.  The 
secretory  signs  reveal  the  progress  of  glandular  destruction 
by  compression.     There    is,  however,  a  possibility  of  being 


422  DISEASES  OF  THE  STOMACH. 

badly  deceived  in  this  matter,  for  secretion  may  be  reduced 
in  quantity  and  in  richness  at  any  period  of  the  evohition  of 
chronic  proliferating  glandular  gastritis  by  acute  interstitial 
gastritis.  But  the  suppressed  hyperchlorhydria  will  reappear 
if  the  complicating  acute  condition  is  relieved  by  protecting 
the  stomach  against  all  irritation  and  b\'  favoring  it  in  its  work 
or  by  giving  it  functional  repose  for  a  few  days.  Sedation 
and  rest  produce — or,  better,  restore — excessive  glandular 
activity,  and  this  sequence  occurs  in  no  other  disease  of  the 
stomach. 

Hypersthenic  gastritis  may  be  complicated  by  m\'asthenia, 
by  pyloric  obstruction,  and,  possibly,  by  motor  insufficiency 
due  to  infiltration  of  the  muscular  layer.  Great  difficulty 
may  be  experienced  in  distinguishing  these  complicated  cases 
with  stagnation  or  retention  from  the  simple  cases  of  Inper- 
sthenic  gastritis  with  prolonged  digestion. 

In  the  contents,  or  in  the  vomit,  or  in  the  wash-water,  signs 
of  gastritis  may  be  found — blood,  altered  cylindrical  cells, 
leukocytes  or  their  nuclei,  and  sometimes  small  pieces  of  the 
vulnerable  mucous  membrane.  The  pieces  of  the  mucous 
membrane  show  the  nature  and  characters  of  the  pathological 
process  in  evolution  at  the  point  from  which  they  come,  which 
is  nearly  always  the  same  as  the  process  which  predominates 
in  other  parts  of  the  stomach.  But  gastritis  is  not  always  of 
the  same  character  and  stage  and  intensity  at  all  points  of  the 
mucosa. 

The  urine  easily  precipitates  the  earthy  phosphates,  but  the 
total  quantity  of  phosphoric  acid  eliminated  in  the  twenty- 
four  hours  may  be  above  or  below  the  normal.  The  total 
quantity  may  reach  as  high  as  five  gm.  or  may  fall  as  low  as 
one  or  two  gm.,  the  average  elimination  being  2^  gm.  in  the 
twenty-four  hours.  But,  be  the  total  quantity  large  or  small, 
the  urine,  as  a  rule,  is  cloudy  when  voided,  and  the  earthy 
phosphates  are  precipitated  by  heat  because  the  urine  is  nearly 
neutral  or  alkaline.  The  diminution  of  the  acidity  of  the  urine 
is  proportionate  to  the  amount  of  acids  found  in  the  stomach. 
The  sum  total  of  the  acidity  of  the  urine  and  of  the  gastric 
juice  in  health  is  a  constant  quantity,  and  this  inverse  re- 
lation is  only  disturbed  in  disease  by  fermentation  and  by 
increased  or  diminished  secretory  activitx',  chiefl)'  of  the  intes- 
tines and  its  annexed  glands  and  of  the  skin.  In  hypersthenic 
gastritis  the  acidity  of  the  urine  is  markedly  diminished  during 
digestion  ;  and  when  digestion  is  prolonged  by  e.xcessive  or 
by  continuous  secretion,  the  reaction  of  tlie  urine  passed  dur- 
ing the  twenty-four  hours  is  nearly  neutral  or  alkaline,  and  it 


GASTRITIS.  423 

may  be  milky  with  precipitated  phosphates.  The  quantity 
of  urea  is  increased  and  the  increase  is  often  absolute.  This 
is  due  in  part  to  the  excessively  albuminous  diet,  to  the  in- 
creased alkalinity  of  the  blood,  and,  probably,  to  the  excessive 
formation  of  peptones.  The  increased  relative  percentage  of 
urea  is  due  to  the  concentration  of  the  urine  by  diminished 
absorption  or  by  increased  loss  of  water  by  the  stomach  and 
intestines  in  vomiting,  retention,  lavage,  and  diarrhea. 

The  chlorids  are  constantly  and  absolutely  diminished  in 
proportion  to  the  vomiting,  retention,  lavage,  and  activity  of 
gastric  secretion.  The  urine  formation,  being  continuous, 
shows  at  each  moment  the  chlorid  percentage  of  the  blood. 
The  blood,  during  the  excessive  gastric  secretion,  is  poorer 
than  normal  in  chlorids.  Consequently,  the  excessive  quan- 
tity of  chlorin  removed  from  the  blood  by  the  stomach 
would,  without  any  other  disturbance,  diminish  the  total 
quantity  of  chlorids  eliminated  in  the  urine  during  the 
twenty-four  hours,  and,  to  a  greater  degree,  during  gastric 
secretion. 

Diagnosis — The  slow  evolution,  the  subjective  and  the 
objective  signs  of  hypersthenic  gastritis,  are  so  characteristic 
that  the  diagnosis  is  not  often  difficult.  The  symptom-group 
presented  at  any  stage  would  fix  the  mind  on  hypersthenic 
gastritis  as  one  of  the  probabilities.  The  differential  diagnosis 
may  be  a  hard  problem. 

Differential  Diagnosis. — Hypersthenic  gastritis  may  be 
primary,  or  it  may  be  a  complication  developing  in  the  orderly 
evolution  of  other  diseases  of  the  stomach,  such  as  myas- 
thenia, displacements,  ulcer,  pyloric  obstruction,  and,  seldom, 
carcinoma.  Without  the  functional  and  bacteriological  signs, 
and  careful  attention  to  the  evolution  of  the  case,  the  differ- 
entiation is  only  a  lucky  or  an  unlucky  guess  at  the  truth. 
If  the  case  be  incompletely  studied,  carcinoma  may  be  easily 
confounded  with  hypersthenic  gastritis.  Pain,  slow  evacua- 
tion of  the  food,  emaciation,  and  cachexia  are  symptoms 
common  to  the  two  diseases.  But  a  comparison  of  the  dis- 
tinctive features  of  the  pain  would  place  in  our  hands  the 
guiding  thread  which  would  lead  to  a  correct  conclusion.  It 
is  useless  to  recall  vague  and  slight  variations  when  the  func- 
tional and  the  bacteriological  signs  are  so  widely  different  in 
the  two  diseases.  The  excessive  hydrochloric  acid  in  the  one, 
and  its  diminution  (little  or  no  H,  little  or  no  C)  in  the  other ; 
the  active  and  rapid  albumin  digestion  in  the  one,  and  its  slow- 
ness, and  incompleteness, and  possible  absence  in  the  other;  the 
absence  of  lactic  acid  fermentation  in  the  one,  and  its  frequent 


424  DISEASES  OF  THE  STOMACJL 

active  formation,  after  stringent  precautions,  in  the  other  ;  the 
almost  constant  cliaracter  of  the  germ  growth  in  the  one,  and 
its  rapid  changes  and  special  character,  in  keeping  with  the 
quick  changes  in  the  chemical  properties  of  the  more  and 
more  stagnant  contents  of  the  other — are  so  many  signs  which 
place  the  two  diseases  in  vivid  contrast.  The  api)etite,  the 
effects  of  food,  the  urine,  the  blood, and  the  evolution,  present 
other  important  differences.  Very  rarely  carcinoma  may  be 
engrafted  on  an  old  ulcer,  and  the  differentiation  may  be  ex- 
ceedingly difficult,  and  may  demand  a  close  and  complete 
study  of  every  little  symptom  and  sign. 

Myasthenia  may  become  accompanied  by  fermentation, 
which  might  produce  secretory  irritation,  and  present  a  symp- 
tom-group closely  resembling  the  stage  of  hj'persthenic 
gastritis  associated  with  prolonged  digestion  and  fermentation. 
Or  the  stagnation  of  the  food  in  myasthenia  might  produce 
supersecretion.  A  knowledge  of  the  evolution  of  the  case  up 
to  the  moment  of  examination  would  clear  up  the  difficulty 
and  reveal  the  primitive  character  of  the  myasthenia  or  of  the 
gastritis.  The  therapeutic  test  gives  valuable  information. 
If  the  stagnation-caused  fermentation  in  myasthenia  is  con- 
trolled by  diet  and  by  lavage,  and  if  the  treatment  suitable  to 
myasthenia  is  adopted,  the  excessive  and  rich  secretion  due 
to  irritation  rapidly  subsides  ;  but  hydrochloric  superacidity 
would  continue  unabated  during  the  prolonged  digestive 
period  in  hypersthenic  gastritis.  The  anatomical  signs  of 
the  gastritis  would  be  absent  in  the  particular  stage  of  my- 
asthenia under  discussion.  Myasthenia  and  hypersthenic 
gastritis  resemble  each  other  only  when  both  are  accompanied 
by  delayed  evacuation  of  the  food  and  by  hydrochloric  super- 
acidity.  The  existence  of  continuous  secretion  excludes 
simple  myasthenia,  and  the  hydrochloric  superacidity  of  my- 
asthenia is  quickly  relieved  by  protecting  the  stomach  from 
irritation  and  by  giving  it  functional  rest.  The  lines  repre- 
senting the  evolution  of  secretion  in  myasthenia  show  sudden 
rises  and  falls.  The  water  test  gives  different  results  in  the 
two  diseases,  for  myasthenia  is  accompanied  by  stagnation  of 
liquids  due  to  motor  insufficiency,  and  hypersthenic  gastritis 
may  be  accompanied  by  prolonged  digestion  due  to  superse- 
cretion. Moreover,  in  myasthenia  expression  is  difficult,  the 
stomach  is  flabby,  loses  its  form,  does  not  retract  as  it  becomes 
empty,  and  splashes  whenever  it  contains  fluid  and  gas. 
Contrary  signs  are  present  in  hypersthenic  gastritis  with 
prolonged  digestion.  For  other  differential  signs,  see  Myas- 
thenia.      But     myasthenia     may    become     complicated     by 


GASTRITIS.  425 

hypersthenic  gastritis,  and  nothing  except  a  knowledge  of 
the  development  of  the  case  could  make  the  differential 
diagnosis.  The  link  belongs  to  either  of  the  two  chains,  and 
the  treatment  is  practically  the  same  when  both  diseases  are 
present. 

Pyloric  obstruction,  gastroptosis,  and  vertical  displacement 
of  the  stomach  may  be  complicated  by  hypersthenic  gas- 
tritis, and  the  history  may  give  the  primary  trouble  ;  the 
gastritis  is  most  frequent  in  men  and  the  displacement  of  the 
stomach  in  women.  For  the  differential  signs,  see  Myas- 
thenia, Displacements  of  the  Stomach,  and  Obstruction  of  the 
Pylorus. 

Treatment. — The  treatment  is  not  the  same  in  all  the 
stages  of  hypersthenic  gastritis,  and  each  of  the  periods 
characterized  by  special  functional  signs  presents  particular 
indications  to  be  met. 

I.  The  Initial  Period The  disease  gathers  more  and   more 

force  and  violence  as  it  progresses,  and  each  day  the  lesions 
become  more  and  more  extensive  and  incurable;  and  hence 
comes  the  stringent  necessity  for  correct  and  consistent  treat- 
ment during  the  initial  period. 

No  more  striking  instance  can  be  found  in  pathology  of 
the  danger  of  neglecting  a  disorder  of  the  stomach  and  of 
not  curing  it  while  in  its  early  stage.  The  prophylactic  treat- 
ment— so  important  on  account  of  the  part  which  every  disease 
of  the  stomach  plays  in  pathogenesis — should  not  be  neglected. 
Prophylaxis  is  particularly  important  in  the  hypersthenic  dis- 
eases, for  they  possess  a  strong  inherent  tendency  to  extend 
and  to  progress.  After  the  initial  period  is  established  the 
indications  are :  {a)  To  protect  the  mucous  membrane  against 
all  forms  of  irritation  ;  {b)  to  maintain  the  balance  of  nutrition 
by  a  suitable  diet;  (r)  to  control  or  utilize  the  excessive 
secretion  ;  {d)  to  treat  the  gross  symptoms ;  {e)  to  prevent 
stagnation  or  retention. 

The  mucous  membrane  may  be  irritated  by  drugs,  by  the 
diet,  and  by  the  excessive  hydrochloric  acidity.  Tonics, 
nervines,  purgatives,  and  all  drugs  which  act  as  local  irritants 
and  excitants  of  secretion  should  be  avoided ;  indeed,  not 
only  avoided,  but  absolutely  prohibited. 

The  physiological  action  of  the  diet  should  be  indifferent, 
non-excitant — no  condiments,  spices,  vinegar,  highly  seas- 
oned sauces,  fermenting  or  decomposing  foods,  or  alcoholic 
drinks.  Such  foods  and  drinks  should  be  selected  as  do  not 
excessively  excite  secretion,  and  which  utilize  the  secretion 
which  is  formed.     Consequently,  all  articles  of  food  which  in 


426  D/SEASES  OF  THE  STOMACH. 

health  leave  during  their  digestion  a  noteworthy  quantity  of 
hydrochloric  acid  free,  should  be  prohibited.  The  excessive 
h)-drochloric  acidity  of  the  contents  irritates  the  mucous 
membrane,  which  in  hypersthenic  gastritis  may  be  particu- 
larly sensitive  to  the  action  of  free  hydrochloric  acid.  The 
diet  is  selected  by  the  needs  of  nutrition,  by  the  functional 
activity  of  the  stomach,  by  the  imperative  necessity  of  avoid- 
ing secretory  irritation,  and  by  the  state  and  functional  power 
of  the  intestines.  The  diet  should  also  be  so  regulated  as  not 
to  tax  the  motor  function  of  the  stomach  too  heavily,  the  de- 
velopment of  motor  insufficiency  rendering  the  disease  much 
more  serious  and  dangerous. 

During  the  initial  period  nutrition  is  commonly  well  pre- 
served, if  the  good  appetite  has  been  heeded.  If  emaciation 
exists  during  this  period  it  is  the  result  not  of  the  disease,  but  of 
faulty  alimentation,  or  possibly  of  a  too  free  use  of  purgatives, 
or  of  intestinal  disease.  Consequently,  the  demands  of  nutri- 
tion are  met  by  maintaining  its  equilibrium.  An  exclusive 
weakening  diet  is  improper,  and  it  is  dangerous  to  weaken 
by  inanition  the  voluntary  and  the  involuntary  muscles,  thus 
favoring  myasthenia  and  prolapse  of  the  stomach,  diminution 
of  abdominal  tension,  intestinal  stasis,  and  inequality  of  the 
circulation.  Guided  by  the  active  peptonization  which  is  one 
of  the  functional  characteristics  of  this  disease,  the  mistake 
is  often  committed  of  prescribing  an  exclusively  albuminous 
diet  incapable  of  maintaining  the  balance  of  nutrition,  except 
possibly  at  a  very  low  level.  The  balance  of  nutrition  can 
be  maintained  and  the  functional  power  of  the  stomach  re- 
spected by  a  diminution  and  a  careful  selection  of  the  carbo- 
hydrates and  fats  in  combination  with  an  increased  quantity 
of  proper  albuminous  foods. 

Physiologically,  the  meats  are  powerful  excitants  of  secre- 
tion, and  their  digestive  products  are  even  more  active,  and  the 
red  meats  require  a  long  time  for  their  digestion.  Conse- 
quently the  meats  are  not  itleal  foods  in  hypersthenic  gas- 
tritis ;  but  they  are  of  great  nutritive  value  and  combine 
large  quantities  of  HCl.  The  meats  and  the  other  albu- 
minous foods  which  are  evacuated  rapidly  by  the  normal 
stomach  should  be  preferred.  In  the  initial  period  there  is  no 
objection  to  milk,  which  is  very  soothing  in  its  action  on  the 
mucous  membrane,  which  combines  the  free  HCl  rapidly,  and 
which  leaves  the  stomach  quickly.  If  milk  is  suitable  to  the 
intestines  it  is  wise  to  begin  the  treatment  with  rest  in  bed,  a 
milk  diet  for  a  few  days,  gradually  adding  eggs,  "vigor 
chocolate,"  stewed  or  broiled  young  chicken,  squab,  lean  and 


GASTRITIS.  427 

fresh  fish,  and  cereals  thoroughly  cooked  and  finely  ground 
or  mashed  after  cooking  and  eaten  with  milk  or  with  cream, 
or  with  broth  or  milk  soup.  Rice,  the  preparations  of  wheat, 
oatmeal,  hominy,  and  cornmeal  mush  are  all  suitable  cereals. 
The  red  meats  may  next  be  permitted,  but  they  should  be 
free  from  fat  and  from  fibrous  tissue,  finely  divided,  properly 
hung,  and  fresh.  Next  come  the  purees  of  green  vegetables, 
mashed  starchy  vegetables,  fruit,  sweets,  and  salads,  in  the 
order  named.  But  the  intestines  may  force  an  exclusion  of 
milk  from  the  diet,  and  the  prescription  of  a  diet  almost 
exclusively  albuminous  (fermentation),  or  a  diet  composed  of 
cereal-thickened  soups,  meat  juice,  cereals,  milk-sugar,  and 
possibly  green  vegetables  and  fruit  (putrefaction).  Butter 
should  be  given  in  moderation,  and  always  fresh,  and  prefer- 
ably unsalted.  Whatever  diet  is  prescribed,  its  action  on 
secretion  and  on  the  motor  function  should  be  watched,  and 
it  should  not  cause  intestinal  putrefaction  or  fermentation. 

With  each  meal — composed  of  food  which  is  finely  divided, 
contains  no  chemical  or  mechanical  irritant,  is  nutritious  in 
small  bulk,  combines  large  quantities  of  HCl,  and  does  not  ex- 
cite secretion  (in  the  normal  stomach)  more  than  it  requires  for 
its  digestion,  which  leaves  the  stomach  rapidly,  and  is  sufficient 
in  quality  and  composition  to  maintain  the  balance  of  nutrition 
— there  should  be  given  one  or  two  glasses  of  fluid,  either 
plain  water,  or  a  slightly  alkaline  water,  or  milk.  A  dry  diet 
is  very  injurious,  the  water  not  only  serving  as  a  diluent, 
diminishing  the  physiological  action  of  the  contents  on 
secretion,  but  also  promoting  the  evacuation  of  the  fluid  con- 
tents into  the  duodenum.  The  prolonged  sojourn  of  the  food 
in  the  stomach  is  a  disadvantage,  exciting  and  prolonging 
secretion  unduly,  and  predisposing  to  the  development  of 
continuous  secretion,  and  to  the  prolongation  of  digestion 
through  excessive  secretion. 

The  hyperchlorhydria  will  be  greatly  influenced  by  the 
protection  of  the  mucous  membrane  against  avoidable  irrita- 
tion. The  condition  of  the  nervous  system  may  also  be  a 
causative  factor  in  the  production  of  the  hyperchlorhydria  and 
every  means  should  then  be  employed  to  enforce  mental  and 
moral  repose.  The  usual  remedies  for  toning  the  nervous 
system  should  be  prescribed,  one  of  the  most  powerful  being 
the  Scottish  douche.  Gastrospinal  and  cervicogastric  seda- 
tive galvanization  may  be  given  a  trial. 

To  control  the  excessively  acid  secretion  no  remedies  are 
more  efficient  than  the  alkaline-sulphate  waters,  of  which 
Carlsbad  water  is  the  type.    The  many  Carlsbad  springs  vary 


428  DISEASES  OF  THE  STOMACH. 

but  little  in  the  quantity  of  sodium  sulphate,  of  sodium  bicar- 
bonate, and  of  salt  which  they  contain,  the  chief  differences 
bein;4  in  the  temperature  of  tlie  water  as  it  comes  from  the 
various  springs.  Some  claim  advantages  for  the  natural  water 
or  natural  salts,  but  this  superiority  of  the  natural  over  the 
artificial  product  may  be  doubted,  although  we  sometimes 
employ  the  "natural"  Sprudel  salts.  The  quantity  of  salt 
(NaCl)  in  the  Carlsbad  water  is  objectionable,  and  it  is  the 
large  quantity  of  this  ingredient  in  the  Saratoga  waters  which 
makes  them  injurious  in  the  treatment  of  hypersthenic  gas- 
tritis. The  salt  either  excites  secretion  (in  small  doses  and 
weak  solutions),  or  it  produces  a  diminution  of  HCl  secretion 
by  causing  acute  gastric  catarrh.  But  in  small  quantity  and 
in  combination  with  an  alkali  it  promotes  peristalsis  and 
possesses  some  other  advantages.  We  ordinarily  prescribe 
artificial  salts  in  the  proportions : 

Sodium  sulphate, 50        50 

Sodium  bicarbonate, 40  or  20 

Sodium  clilorid 10  5. 

The  first  proportion  (50:40:  10)  is  more  strongly  ant- 
acid, and  the  second  (50:  20:  5)  acts  more  decisively  on  the 
bowels,  A  level  teaspoonful  of  the  mixed  salts  should  be 
taken,  by  sips,  dissolved  in  a  glass  of  hot  water,  one  hour 
before  breakfast.  The  dose  should  be  increased  (propor- 
tionate increase  of  hot  water)  or  decreased  until  only  one 
full  soft  movement  of  the  bowels  results.  The  cure  should 
be  continued  for  three  to  four  weeks,  the  patient  taking  but 
little  exercise.  The  Carlsbad  cure  should  not  be  ordered  for 
the  old  and  the  weak,  or  for  patients  with  valvular  heart 
disease. 

A  very  valuable  remedy,  both  to  influence  secretion  and 
to  allay  the  excessive  irritability  and  the  morbid  sensibility 
of  the  mucous  membrane,  is  the  nitrate  of  silver  (i  :  2000) 
douche,  employed  once  a  week.  Or  a  tablespoonful  of  a 
solution  of  one  grain  to  two  ounces  of  distilled  water  may 
be  given  every  morning  on  an  empty  stomach.  Theoreti- 
cally, belladonna,  on  account  of  its  inhibitory  action  on 
secretion,  and  its  diminution  of  reflexes,  is  indicated;  and, 
practically,  it  is  of  very  great  value  when  given  in  small 
doses  (-\j  to  Tj^jj-  of  a  gr.)  before  meals.  Subnitrate  of  bismuth 
is  very  valuable  when  given  in  the  large  doses  and  manner  re- 
commended by  Kleiner.  Small  doses  ofergot  control  the  exces- 
sive flow  of  blood  to  the  mucous  membrane  during  digestion. 

Pain,  vomiting,  and  constipation  may  require  special  atten- 


GASTRITIS.  429 

tion.  To  relieve  the  pain,  no  remedy  is  so  effective  as  the 
aqueous  extract  of  opium,  which  may  be  combined  with  a 
good  extract  of  cannabis  indica  and  extract  of  belladonna, 
j^Q-  of  a  grain  of  each  being  employed.  Codein  is  not  so  effi- 
cient, but  does  not  increase  the  constipation.  These  anodynes 
should  only  be  used  when  alkalies,  diet,  rest,  the  warm  com- 
press, belladonna,  ergot,  Carlsbad  salts,  nitrate  of  silver,  and 
bismuth  fail  to  give  relief.  It  is  useless  to  treat  the  vomit- 
ing with  a  symptomatic  remedy,  the  act  being  conservative 
and  protective.  Better  encourage  it  by  giving  lukewarm 
water,  or  wash  out  the  stomach. 

In  addition  to  the  remedies  directed  against  the  conditions 
which  underlie  it,  during  the  periodical  attacks  of  gastric 
intolerance  a  Winternitz  or  Priessnitz  compress  should  be 
placed  on  the  stomach  half  an  hour  before  the  meal,  and 
kept  there  during  the  period  of  gastric  digestion ;  and  in 
all  cases  the  compress  should  be  worn  at  night.  The  con- 
stipation is  commonly  relieved  by  the  prescribed  mineral 
water,  but  the  bowels  may  exceptionally  require  evacuation 
by  a  warm  water  enema,  to  which  a  teaspoonful  of  neutral 
glycerin  may  be  added,  or  by  gluten  or  glycerin  supposi- 
tories. 

2.  During  the  second  period  digestion  is  prolonged.  The 
evacuation  of  the  stomach  is  delayed,  and  with  the  delayed 
evacuation  is  associated  excessive  or  continuous  secretion, 
and  sometimes  fermentation.  The  remedies  used  in  the  first 
period  may  also  now  be  useful,  but  the  excessive  or  continu- 
ous secretion  must  be  relieved  and  the  diet  changed,  so  as  to 
avoid  producing  or  increasing  the  fermentation,  and  to  make 
the  demand  on  the  motor  function  as  light  as  possible. 

Milk  must  be  removed  from  the  diet  list  and  the  butter 
reduced  to  a  minimum  quantity.  The  fermentation  may  be 
controlled  by  an  exclusive  meat  diet  for  twenty-four  or  forty- 
eight  hours  ;  but  the  fermentation  will  begin  anew  with  the 
addition  of  the  carbohydrates,  provided  the  long  period  of 
gastric  digestion  has  not  been  shortened.  But  often  with  this 
temporary  change  in  the  diet,  combined  with  rest,  hydro- 
therapy, massage,  and  gastrospinal  galvanization,  the  fermen- 
tation may  be  controlled.  A  glass  of  hot  water  should  be 
slowly  sipped  every  morning  an  hour  before  breakfast,  during 
the  intervals  when  the  Carlsbad  cure  is  not  in  progress. 
This  soothing  and  cleansing  remedy  is  far  preferable  to 
stomach  washing,  as  long  as  the  morning  fasting  stomach  is 
empty  and  there  is  no  fermentation.  The  diet  during  this 
stage  must  not  be  reduced  below  the  needs  of  nutrition,  and 


430  DISEASES  OF  THE  STOMACH. 

during  the  temporary  employment  of  an  exclusive  diet  to  aid 
in  suppressing  the  fermentation  a  nutrient  enema  should  be 
given  daily.  Stomach  washing  is  more  beneficial  than  in  the 
initial  period,  and  it  may  be  employed  before  the  evening 
meal,  or  at  bedtime,  or  in  the  morning  before  breakfast,  as 
there  may  be,  respectively,  continuous  secretion,  or  excessive 
secretion,  or  continuous  secretion  and  fermentation.  What- 
ever diet  be  adopted,  it  is  absolutely  necessary  that  the 
stomach  should  be  empty  when  a  meal  is  eaten.  Conse- 
quently it  may  be  best  to  allow  only  two  meals  a  day, 
separated  by  a  long  interval,  and  to  use  the  tube  twice  a  day 
when  secretion  is  prolonged  and  does  not  cease  with  the 
evacuation  of  the  stomach,  or  when  secretion  is  continuous. 
If  the  supersecretion  is  exclusively  digestive,  it  may  be  best 
to  give  a  liquid  and  non-excitant  diet,  the  frequent  small 
meals  being  separated  by  intervals  long  enough  to  permit  the 
evacuation  of  the  stomach.  If  secretion  is  continuous,  rectal 
feeding  is  the  best  remedy.  All  forms  of  excessive  secretion 
are  benefited  by  belladonna,  ergot,  nitrate  of  silver,  and  bis- 
muth. 

3.  During  the  terminal  period  the  treatment  embodies  the 
same  general  principles  which  have  regulated  the  plan  of 
medication  in  the  other  stages.  The  gastric  secretion  may 
not  be  excessively  rich,  and  the  diet  may  be  made  more 
liberal.  Interstitial  inflammation  is  the  new  factor  with  which 
we  have  to  deal,  and  it  may  require,  for  the  relief  of  its  acute 
exacerbations,  even  more  careful  protection  of  the  mucous 
membrane  against  irritation,  and  temporary  but  complete 
functional  repose.  It  may  be  necessary  to  confine  the  patient 
to  bed,  and  to  employ  rectal  feeding  for  a  few  days.  When 
secretion  becomes  diminished  in  quantity  and  richness, 
it  may  be  advisable  to  douche  the  interior  of  the  stomach 
with  a  physiological  salt  solution,  or  to  administer  five  grains 
of  salt  in  a  glass  of  hot  water  before  breakfast,  adding  enough 
sodium  sulphate  to  regulate  the  bowels;  for  the  intestines 
demand  the  same  solicitude  and  watching  as  in  the  other 
stages  of  chronic  hypersthenic  gastritis. 


III.  GASTRITIS  GLANDULARIS  ATROPHICANS,  OR  ATROPHY 
OF   THE  GASTRIC  GLANDS. 

Complete  primary  atrophy  or  degeneration  of  the  secreting 
structure  of  the  stomach  is  not  a  frequent  disease.  It  does 
not  embrace  all  cases  in  which  there  is  prolonged  absence  of 


GASTRITIS.  43 1 

gastric  secretion,  for  this  condition  may  occur  in  severe 
adenasthenia  gastrica  complicated  by  interstitial  inflammation, 
and  as  a  termination  of  other  forms  of  benign  and  of  malig- 
nant gastritis.  It  does  not  embrace  all  cases  of  anadenia  ven- 
triculi.  The  pathological  process  is  atrophic — a  progressive 
parenchymatous  degeneration. 

Glandular  atrophy  may  be  secondary.  The  severe  infec- 
tious and  the  chronic  diseases  which  run  a  very  long  course 
and  are  accompanied  by  great  emaciation  and  loss  of  strength, 
produce  more  or  less  parenchymatous  degeneration  of  the 
glandular  membrane  of  the  stomach,  as  do  also  cancer  of  the 
breast,  of  the  uterus,  and  of  the  intestines.  This  result  is  not 
constant,  but  is  common  in  the  advanced  stages  of  malignant 
neoplasms  of  other  organs  than  the  stomach. 

Diseases  of  the  stomach  itself  may  destroy  its  glandular 
membrane.  This  is  specially  true  of  carcinoma  of  the  stomach. 
The  destruction  is  either  direct,  the  secreting  cells  not  being 
regenerated,  or  indirect,  the  glands  being  destroyed  by  com- 
pression and  by  cellular  degeneration. 

But  atrophy  of  the  gastric  glands  may  be  primary  and  not 
due  to  any  other  local  or  distant  disease,  or  it  may  represent 
the  terminal  period  of  other  forms  of  gastritis.  It  is  frequent 
in  the  marasmus  of  old  age,  but  is  then  rarely  complete. 
Chronic  inanition  may  also  produce  it,  and  typical  forms 
result  from  phosphorus-poisoning  and  from  arteriosclerosis. 
It  may  be  due  also  to  the  chronic  toxemia  of  nutritive 
troubles,  or,  at  least,  for  unknown  reasons,  the  parenchyma 
of  organs  at  times  degenerates  and  dies  instead  of  becoming 
inflamed.  The  mucous  membrane  of  the  stomach  is  not 
exempt  from  this  sort  of  degeneration,  and,  in  spite  of  its 
usual  great  resistance,  exceptionally  and  more  markedly  and 
sometimes  exclusively  becomes  affected  by  it. 

Pathological  Anatomy. — Glandular  atrophy  may  be  pri- 
mary or  it  may  represent  the  terminal  period  of  catarrhal  and 
interstitial  gastritis. 

Interstitial  gastritis  may  be  present  in  catarrhal  gastritis 
and  in  proliferating  glandular  gastritis,  and  its  degree  influ- 
ences the  evolution  of  these  forms  of  gastritis.  It  may  de- 
velop before  the  productive  inflammation  of  the  mucous 
division  of  the  mucosa  (catarrhal  gastritis),  or  it  may  begin 
during  the  evolution  of  catarrhal  gastritis.  It  rarely  precedes 
proliferating  glandular  gastritis,  but  is  common  in  the  terminal 
period.  It  is  the  only  productive  process  which  occurs  in 
gastritis  glandularis  atrophicans.  But  in  some  cases  the  inter- 
stitial inflammation  dominates  the  pathological  changes,  and 


432 


DISEASES  OF  THE  STOMACH. 


destroys  the  glands  by  compression.  The  changes  in  the 
secreting  cells  are  partly  degenerative  and  partly  irritative 
and  productive.  It  is  the  interstitial  inflammation  which 
causes  change  of  form  during  the  evolution  of  gastritis,  and 
produces  atypical  clinical  cases.  If  the  interstitial  inflamma- 
tion is  primary  and  dominates  the  evolution  of  the  morbid 
process,  during  the  period  of  ad\'anced  compression-atrophy, 
the  mucous  membrane  becomes  grayish,  smooth,  and  hard. 
Here  and  there,  imbedded  in  the  newly-formed  connective 
tissue,  may  be  seen  the  remains  of  the  gastric  tubules.  The 
compression-atrophy  is  most  marked  in  the  pyloric  region. 
The  submucosa  is  thickened  and  infiltrated,  and  the  infiltra- 
tion often  extends  to  the  muscular  layer.     The  wall  of  the 


Fig.  23.— Gastritis  chronica  catarrhalis  (terminal  atrophy).    X  115.    (Authors'  specimen.) 


stomach  is  hard,  thickened,  and  the  stomach  is  reduced  nota- 
bly in  size.  Catarrhal  gastritis,  in  the  manner  already  de- 
scribed, may  end  in  complete  destruction  of  the  glandular 
layer. 

Glandular  atrophy  also  occurs  as  the  expression  of  a  pri- 
mary cellular  degeneration.  The  stomach  is  then  usually 
small  and  its  wall  is  very  thin.  The  inner  surface  is  smooth 
and  of  a  pale  yellow  or  reddish  color,  or  sometimes  waxy. 
Gastritis  glandularis  atrophicans  is  characterized  by  degen- 
eration of  both  the  cylindrical  cells  and  the  cells  wliich  line 
the  glands.  Consequently,  both  the  mucous  and  the  glandular 
divisions  of  the  mucosa  are  affected  by  the  cellular  degenera- 
tion.    The  cylindrical  cells   are  converted  into  goblet  cells 


GASTRITIS. 


433 


and  into  columnar  cells  with  striated  ends.  Some  are  short 
and  indistinct  in  outline.  The  protoplasm  loses  its  affinities 
for  stains,  and  falls  into  a  pale  granular  mass.  The  chief  and 
the  border  cells  can  not  be  distinguished,  or  only  here  and 
there  can  be  seen  a  cell  which  preserves  its  identity.  The 
cells  lose  their  form,  diminish  in  size,  yield  to  the  pressure 
due  to  the  accumulation  of  degenerate  cells,  and  their  cyto- 
plasm loses  its  affinities  for  stains  and  falls  into  a  pale  granu- 
lar mass.  The  nuclei  also  undergo  chromatosic  degenera- 
tion. Finally,  the  mucosa  is  converted  into  a  soft  mass  of 
embryonic  cells,   mixed   with   granular   masses    and  hyaline 


y.  '  i^te 


•^r:-:-*.  ^;<:/,^  •Z:'^^^:-.  ,/.>.•• 


•*"*      *    •■     ' 


Fig.  24. — Gastritis  glatidiilaris  atropliicans.     X  115.     (Authors'  specimen.) 


bodies,  which  represent  degenerated  secreting  cells  and  degen- 
erated wandering  leukocytes.  Here  and  there  may  be  seen 
fragments  of  partly  preserved  glands,  and  in  other  parts  of  the 
mucosa  may  be  found  glands  whose  cells  are  undergoing 
degeneration.  The  surface  of  the  mucosa  is  without  folds, 
vulnerable,  without  prominences  or  depressions,  and  covered 
with  blood-stained  mucus  and  coagulated  protoplasm.  The 
interglandular  and  subglandular  tissues  are  infiltrated  with 
embryonic  cells,  with  disintegrating  leukocytes,  with  esino- 
phile  cells,  and  with  irregularly  outlined,  flattened,  or  elon- 
gated  nucleated   cells  with  granular  protoplasm.     The  sub- 

mucosa  is  somewhat  thickened,  and  the  walls  of  the  arterioles 

28 


434  DISEASES  OF  THE  STOMACH. 

in  some  cases  undergo  amyloid  degeneration.  Tlie  muscular 
layer  is  commonly  left  intact  in  the  earlier  stages,  but  it  may 
become  infiltrated  and  lose  its  power.  The  morbid  process 
is  essentially  a  cellular  degeneration  without  reparative  effort, 
which  is  accompanied  by  interstitial  inflammation.  The  final 
result  is  complete  glandular  destruction.  Such  is  atrophy  of 
the  gastric  glands — a  primary  and  distinct  form  of  gastritis. 

Clinical  Description. — The  evolution  of  glandular  atrophy 
may  be  divided  into  three  periods  of  variable  duration  :  the 
periods  of  compensation,  of  gastric  symptoms,  and  of  inani- 
tion. The  patient  is  usually  in  the  last  third  of  the  normal 
course  of  life,  but  gastric  atrophy  may  occur  at  an  early  age. 

The  period  of  compensation  may  be  short  or  may  extend 
over  a  number  of  \'ears.  During  this  period  there  are  no 
digestive  symptoms,  and  the  body  remains  well  nourished. 
The  intestines  do  perfectly  the  chemical  work  of  the  stomach, 
the  integrity  of  the  motor  function  of  the  stomach  being  pre- 
served. The  secretion  of  the  stomach  is  diminished,  or  even 
completely  lost.  The  hydrochloric  acid  and  the  ferments  are 
all  about  equally  decreased  or  lost.  The  quantity  of  mucus 
in  the  test-meal  contents  and  in  the  lavage  water  may  be  in- 
creased or  it  may  be  diminished.  Nutrition  is  maintained  by 
the  intestines  without  digestive  disturbance. 

The  period  of  gastric  symptoms  is  also  variable  in  duration, 
and  may  exist  from  the  beginning  of  the  disease.  These  symp- 
toms are  often  ill-defined,  but  sometimes  characteristic.  There 
may  be  a  little  heaviness,  or  fullness,  or  flatulency  after  meals, 
attended  by  discomfort,  occasionally  by  bilious  or  alimentary 
vomiting,  sometimes  by  diarrhea,  but  more  frequently  by 
constipation.  In  cases  of  glandular  atrophy,  diarrhea  is  easily 
produced  by  dietetic  errors  and  excesses.  The  vomit  some- 
times contains  blood,  particularly  when  grave  oligocythemia  is 
present.  The  appetite  is  diminished,  often  lost,  a  disgust  for 
meats  may  e.xist,  but  the  cereals,  fish,  milk,  vegetables,  and 
fruits  are  eaten  more  readily,  without,  however,  relieving  ma- 
terially the  distress.  During  short  intervals  of  two  or  three 
weeks  the  symptoms  may  disappear,  but  again  return.  More 
characteristic  is  the  digestive  pain,  which  sometimes  continues 
until  the  stomach  is  empty,  and  often  begins  as  soon  as  the 
food,  or  even  water,  enters  the  stomach.  The  pain  is  almost 
invariably  e.xcited  when  the  stomach  is  distended  with  food 
or  by  inflation.  The  pain  is  sometimes  very  severe,  and  when 
associated  with  the  functional  signs  of  atrophy  is  of  very  great 
diagnostic  value.  During  the  period  of  gastric  repose  par- 
oxysmal peristaltic    pains  may  develop   in  the  colon.     The 


GASTRITIS.  435 

epigastrium  may  be  very  sensitive.  Vomiting  is  an  occa- 
sional symptom,  and  the  stomach  may  become  intolerant. 

The  gastric  and  the  inanition  periods  are  not  clearly  separ- 
ated. The  two  may  begin  together,  or  the  inanition  may 
commence  with  intestinal  disturbance,  particularly  diarrhea, 
and  the  gastric  symptoms  appear  later.  Sometimes  the  gastric 
symptoms  may  never  become  prominent,  or  they  may  only 
appear  periodically  after  days  of  comfort. 

The  inanition  is  usually  progressive,  and,  unless  due  to  a 
temporary  disturbance  of  the  intestines  or  to  improper  diet, 
it  produces  death  by  starvation  in  six  or  eight  months.  The 
patient  becomes  weak,  pale,  cachectic,  and  sometimes  neuras- 
thenic. Dyspnea  and  palpitation  occur  on  the  least  effort. 
The  mind  becomes  quickly  tired,  and  insomnia  is  often  obsti- 
nate. But  emaciation  may  not  be  great,  as  the  bloodless  and 
inactive  patient  burns  but  little  of  the  body  fat.  Nearer  to  the 
fatal  termination,  the  fat  in  the  food  is  better  absorbed  by  the 
intestines  than  is  any  other  food.  Inanition  delirium  and 
sometimes  coma,  precede  the  death  of  the  prostrated,  blood- 
less, cachectic,  and  starved  patient. 

Symptomatology. — The  loss  of  appetite,  the  vague  diges- 
tive symptoms,  vomiting,  constipation,  and  diarrhea  are  com- 
mon to  a  number  of  severe  chronic  diseases  of  the  stomach, 
and  have  little  diagnostic  value.  Of  more  importance  are  the 
pain  and  inanition.  Severe  paroxysms  of  pain,  usually  diges- 
tive, but  rarely  occurring  when  the  stomach  should  be  empty, 
and  then,  as  a  rule,  excited  by  a  reflux  of  bile,  associated  with 
greatly  diminished  or  lost  gastric  secretion,  and  with  preser- 
vation of  the  motor  function,  should  arouse  suspicion  of 
glandular  atrophy.  Pain,  in  association  with  nearly  lost 
gastric  secretion,  occurs  in  carcinoma,  but  is  very  rare  in 
chronic  asthenic  gastritis  and  adenasthenia  gastrica. 

The  inanition  may  become  very  pronounced,  be  even 
fatal,  and  characterizes  one  of  the  stages  of  the  disease.  Its 
coexistence  with  motor  sufficiency  of  the  stomach,  and  with 
the  employment  of  a  diet  containing  nutriment  enough  to  meet 
the  requirements  of  the  body,  and  its  increase  and  decrease  in 
relation  with  the  digestive  and  absorptive  work  done  by  the 
intestines,  are  distinctive  features.  It  may  be  progressive  in 
spite  of  every  effort  to  nourish  the  patient,  and  may  be  accom- 
panied by  the  usual  signs  of  grave  oligocythemia.  Emacia- 
tion does  not  occur  until  intestinal  digestion  and  absorption 
begin  to  fail,  unless  the  diet  is  insufficient.  The  body  fat  may 
be  preserved  even  when  the  patient  is  almost  bloodless. 

The    severe    anemia    is    generally    secondary.     The    total 


436  DISEASES  OF  THE   STOMACH. 

quantity  of  the  blood  is  diminished,  but  there  are  often  no 
hemic  murmurs,  and  the  hemoglobin  percentage  is  less  reduced, 
as  a  rule,  than  that  of  the  red  corpuscles.  There  is  leuko- 
penia, but  the  polynuclear  white  cells  largely  predominate,  and 
there  are  megalocytes,  poikilocytosis,  and  microcytes,  but  no 
megaloblasts.  Lymphemia  and  nucleated  red  corpuscles  of 
normal  (normoblasts)  or  of  abnormal  (microblasts,  megalo- 
blasts, gigantoblasts)  sizes  are  rarely  found  in  the  secondary 
grave  oligocythemia  of  atrophy  of  the  gastric  glands.  As  a 
result  of  the  disease  of  the  blood  there  may  be  hemorrhages 
in  the  retina,  from  the  mucous  membranes,  and  in  the  structure 
of  the  various  organs.  In  a  case  of  the  authors,  with  hemor- 
rhages but  no  megaloblasts,  the  liver  and  kidneys  contained 
no  accumulation  of  iron,  and  the  stomach  was  small,  thin,  and 
the  gastric  glands  were  completely  atrophied.  The  glands  of 
the  stomach  may  undergo  fatty  degeneration  in  grave  oligo- 
cythemia due  to  other  causes,  just  as  do  the  kidneys  and  the 
heart  muscle.  The  anemia  caused  by  atrophy  of  the  gastric 
glands  is  simply  a  grave  secondary  inanition  anemia,  accom- 
panied by  an  altered  plasma  which  becomes  hematocytolytic, 
and  by  diminished  resistance  and  insufficient  development  of 
the  red  and  white  corpuscles. 

The  physical  signs  are  of  little  diagnostic  value.  The 
stomach  is  usually  small  and  does  not  splash  abnormally. 
The  epigastric  tenderness  may  create  a  false  suspicion  of 
ulcer  or  of  carcinoma.  The  physical  signs  po-ssess  chiefly  a 
negative  diagnostic  value. 

The  functional  signs  of  atrophy  of  the  gastric  glands  con- 
stitute, clinically,  its  chief  distinctive  features.  The  motor 
function  is  normal,  and  if  the  food  be  fluid  and  finely  divided 
it  usually  leaves  the  stomach  even  earlier  than  in  health.  But 
motor  insufficiency  does  not  necessarily  exclude  glandular 
atrophy,  as  the  motor  insufficiency  may  be  an  accidental  asso- 
ciation, produced  by  other  causes,  but  never  by  the  glandular 
atrophy.  There  is  no  dclaj'ed  evacuation  of  the  stomach 
produced  by  excessive  secretion,  or  by  continuous  secretion, 
or  by  obstruction,  or  by  spasm  of  the  pylorus,  or  by  weak- 
ness or  infiltration  of  the  muscular  layer.  The  stomach 
grows  small  as  its  wall  becomes  thin. 

After  the  test-breakfast  the  contents  contain  neither  HCl 
(free  or  in  organic  combination),  nor  pepsin,  nor  labferment, 
nor  the  mother  substances  of  the  ferments.  There  may  be 
little  or  no  excess  of  mucus,  unless  it  be  swallowed,  and  only 
a  few  c.c.  of  water  or  secretion  fluid.  Such  is  the  almost 
total  absence    of  secretion   when    the    atrophy  is    complete. 


GASTRITIS.  437 

When  incipient  or  partial,  all  the  products  of  secretion  simply 
diminish  more  or  less. 

In  the  expressed  contents — small  in  quantity,  thick,  contain- 
ing little  water,  with  the  roll,  as  swallowed,  unchanged  physi- 
cally, covered  with  mucus  or  mixed  with  a  little  slimy  fluid — 
are  found  none  of  the  products  of  pepsin-hydrochloric  diges- 
tion. Starch  digestion  is  normal,  and  the  reaction  with  Fehl- 
ing's  solution  is  positive. 

There  are  no  characteristic  bacteriological  signs.  The 
germs  that  are  found  have  been  swallowed.  There  may  be  a 
trace  of  lactic  acid  (ether  extract),  but  never  after  previous 
lavage.  Sometimes  there  is  a  little  butyric  acid.  The  total 
acidity  may  vary  from  zero  to  8  or  lo.  The  sweetened 
contents  yield  no  gas  in  the  fermentation  tubes. 

Blood  is  sometimes  vomited,  and  usually  comes  from  con- 
gested vessels  about  the  cardia.  An  important  anatomical 
sign  of  differential  diagnostic  value  is  the  absence  of  well- 
preserved  gastric  epithelium  in  the  morning  washings  from 
the  stomach.  The  tube  is  rarely  used  without  obtaining  a 
little  bloody  exudate,  and,  frequently,  pieces  of  the  degener- 
ated mucous  membrane,  goblet  cells,  and  leukocytes  from 
the  interglandular  tissues. 

Neither  digestive  leukocytosis  nor  the  diminished  acidity  of 
the  urine  secreted  during  the  period  of  functional  activity  of 
the  stomach  occurs.  Digestive  leukocytosis,  however,  occurs 
during  the  stage  of  compensation  and  before  inanition  and 
anemia  develop. 

Differential  Diagnosis. — Atrophy  of  the  gastric  glands 
may  be  confounded  with  adenasthenia  gastrica,  chronic  as- 
thenic gastritis,  and  carcinoma. 

Adenasthenia  gastrica  is  most  common  in  hysterical  or  neu- 
rasthenic women,  between  the  ages  of  fifteen  and  thirty-five. 
Gastric  atrophy  is  more  common  in  men  after  the  thirty- 
fifth  year.  The  dynamic  affection  is  often  remittent  in  its 
course,  being  accompanied  by  rapid  changes  in  secretion. 
Atrophy  of  the  gastric  glands,  after  digestive  compensation  is 
lost,  often  runs  a  rapid  and  progessive  course  to  a  fatal  termi- 
nation within  a  year.  Secretion  once  lost  is  never  recovered. 
In  adenasthenia  gastrica  the  acid  secretion  varies  from  a 
slight  decrease  of  the  normal  quantity  to  a  total  temporary 
loss.  There  may  be  little  or  no  free  HCl  in  the  contents  after 
the  test-breakfast,  or  only  combined  hydrochloric  acid,  or 
none  whatever.  The  secretory  activity  of  the  stomach  now 
drops,  now  rises  rapidly,  and  may  nearly  always  be  excited  so 
as  to  give  plain  ferment  tests.      The  secretion  of  mucus  in 


438  DISEASES  OF  THE  STOMACH. 

adenasthenia  gastrica  is  never  increased,  and  may  not  be  even 
altered  when  the  acid  secretion  is  completely  suppressed. 
The  morning  washings  of  the  stomach  contain  well-preserved 
and  perfectly  staining  gastric  epithelium,  which  is  never  found 
in  glandular  atrophy.  In  the  dynamic  affections  there  is  no 
vomiting,  no  paro.xysmal  pain,  or,  if  the  diet  is  sufficient,  there 
is  no  emaciation,  inanition,  grave  anemia,  nor  cachexia,  nor 
signs  of  an  anatomical  disease  of  the  mucous  membrane. 
Indeed,  the  two  diseases  are  not  likely  to  be  confounded, 
except  during  the  compensation  stage  of  glandular  atrophy. 
Moreover,  adenasthenia  gastrica  never  produces  persistent 
achylia.  The  disproportion  between  the  glandular  destruc- 
tion in  cases  of  so-called  "simple  achylia"  and  the  complete 
suppression  of  secretion  is  no  proof  of  the  nervous  nature  of 
"simple  achylia."  There  may  be  complete  suppression  of 
secretion  in  severe  asthenic  gastritis  accompanied  by  acute  or 
subacute  interstitial  inflammation.  Interstitial  gastritis  may 
reduce  the  excessively  rich  secretion  of  hypersthenic  gastritis 
to  hypochylia.  In  both  cases  the  chief  and  border  cells  may 
be  in  perfect  preservation,  and  this  condition  is,  consequently, 
out  of  harmony  with  the  depression  of  secretion.  The  nervous 
system  may  be  highly  toned  without  influencing  secretion  in 
so-called  nervous  or  "simple  achylia."  Where  pieces  of 
mucous  membrane,  in  our  experience,  have  shown  the  par- 
tial preservation  of  the  peptic  glands  and  cells,  there  has  been 
marked  interstitial  infiltration,  and,  usually,  advanced  changes 
in  the  mucous  division  of  the  mucosa;  or  other  pieces  ob- 
tained from  the  same  cases  have  shown  the  characteristics  of 
glandular  atrophy.  We  can  not  admit,  therefore,  the  exist- 
ence of  persistent  achylia  as  a  dynamic  affection.  Secretion 
may  sometimes  be  restored  by  treatment  when  the  achylia 
is  due  to  interstitial  gastritis. 

Some  cases  of  carcinoma  of  the  stomach  may  be  readily 
mistaken  for  glandular  atrophy.  Cancer  nearly  always  pro- 
duces motor  insufficiency  and  an  active  bacillary  germ  growth. 
This  is  a  valuable  differential  sign,  and  is  conclusive  when 
associated  with  lactic  acid  formation.  But  motor  insufficiency 
may  not  develop  until  late  in  the  evolution  of  some  cases  of 
cancer,  and  may  never  develop  in  some  cases  of  scirrhus. 
The  ferments  do  not  completely  disappear  until  late  in  the 
cachectic  stage  of  cancer.  The  blood  changes  are  unlike 
those  of  gastric  atrophy.  Hemorrhage  is  more  frequent,  pain 
is  more  constant,  and  a  tumor  can  often  be  detected.  Mucus 
in  large  quantity,  and  cancer  cells  or  exfoliations,  may  be 
found  in  the  vomit,  in  the  morning  washings,  and  in  the  ex- 


GASTRITIS.  439 

pressed  contents  after  a  test-breakfast.  The  clinical  history, 
particularly  the  state  of  the  health  of  the  patient  when  the 
trouble  began,  may  often  give  weight  to  the  one  or  the  other 
side.  Both  diseases  may  be  progressive  and  may  rapidly 
terminate  in  death  by  inanition,  the  inanition  being  toxic 
(protoplasm  poison)  in  the  one  and  intestinal  in  the  other. 
The  differentiation  must  be  made  by  a  careful  study  of  all  the 
circumstances,  symptoms,  and  signs.  Some  are  found  only 
in  the  one  or  the  other  disease ;  some  are  more  common  in 
the  one  than  in  the  other.  The  ill-defined  atypical  cases  of 
the  two  diseases  may  so  closely  resemble  each  other  as  to 
leave  the  physician  in  ignorance  and  doubt.  Atrophy  may 
be  a  complication  of  cancer,  developing  during  the  cachectic 
period. 

Chronic  asthenic  gastritis  is  a  painless  disease  ;  the  diges- 
tive symptoms  vary  with  the  quality  (solid  or  liquid)  of  the 
food,  and  mucus  is  secreted  in  excess.  In  the  uncomplicated 
cases  the  nutrition  of  the  body  is  well  preserved,  and  there 
is  properly  no  extreme  emaciation  nor  grave,  progressive 
anemia.  The  course  is  long  and  tedious.  These  symptoms 
and  signs  are  all  in  contrast  with  those  of  glandular  atrophy, 
which  may,  however,  develop  as  the  anatomical  termination 
of  chronic  asthenic  gastritis.  The  clinical  history  and  evolu- 
tion are  then  the  chief  distinctive  features.  Both  these  forms 
of  atrophy  may  be  accompanied  by  paroxysms  of  pain. 
Chronic  hypersthenic  gastritis  is  widely  different  in  its  mani- 
festations, evolution,  and  objective  signs  from  atrophy  of  the 
gastric  glands. 

Prognosis. — Atrophy  of  the  gastric  glands  may  not  in  itself 
seriously  compromise  the  general  health  nor  shorten  life.  It 
calls  into  activity  all  the  reserve  forces  of  digestion,  but  the 
healthy  intestines  stand  between  it  and  inanition.  With  good 
digestive  hygiene  and  a  proper  diet,  digestive  compensation 
need  not  be  disturbed.  But  even  when  completely  compen- 
sated, the  disease  constitutes  a  weakness,  and  opens  the  portals 
to  gastro-intestinal  infection. 

When  digestive  compensation  is  destroyed  and  the  intes- 
tine fails  to  do  its  work,  the  situation  becomes  grave.  The 
prognosis  is  bad  when  the  inanition  and  anemia  are  marked 
and  are  uncontrollable  by  proper  treatment.  The  disease  is 
in  the  stomach,  but  the  prognosis  is  given  by  the  intestines, 
by  the  state  of  nutrition  and  of  the  blood,  and  by  the  com- 
plications, and,  when  the  glandular  atrophy  is  secondary,  by 
the  causative  disease.  Atrophy  of  the  gastric  glands  does 
not  render  the  preservation  of  good  health  impossible,  but  it 


i140  DISEASES  OE   THE   STOMACH. 

is  a  constant  menace,  and  may  lead  to  death  by  inanition 
within  a  few  months. 

Treatment. — In  the  treatment  of  atrophy  of  the  gastric 
glands  physical  remedies  have  no  place.  Lavage,  the  intra- 
gastric douche,  intragastric  electrization,  and  massage  are  not 
only  without  purpose,  but  may  injure  the  exceedingly  vulner- 
able mucous  membrane.  The  stomach  must  be  protected  at 
all  hazards,  for  acute  inflammation  may  be  excited  and  the 
motor  function  thus  impaired.  No  effort  need  be  made  to 
excite  or  to  restore  secretion.  This  function  of  the  stomach 
is  irreparably  lost.  Physiological  treatment  is  useless  and 
harmful.  There  is  no  hope  of  making  a  degenerate  cell  work, 
or  of  restoring  its  waning  vitality  by  stimulation  and  excita- 
tion. Excitant  medication  only  hastens  the  death  of  the  cell, 
or  if  the  cell  be  already  destroyed  excitation  is  altogether  out 
of  place.  The  only  local  treatment  of  a  degenerate  cell  which 
is  beneficial  is  most  scrupulous  and  vigorous  protection.  But 
the  motor  function  of  the  stomach  should  be  carefully  guarded 
and  strengthened. 

This  can  best  be  done  by  careful  digestive  hygiene,  h}'dro- 
therapy,  faradism,  and  in  some  cases  by  the  use  of  a  few 
drugs.  Rest  before  and  after  each  meal,  the  avoidance  of 
overloading  the  stomach,  and  the  exclusion  of  innutritions, 
indigestible,  and  irritating  food  and  drinks  are  always  neces- 
sary. Water  should  be  used  to  tone  the  neuromuscular 
systems.  The  Scottish  douche  over  the  abdomen  and  lower 
extremities  is  an  excellent  procedure  the  value  of  which  is 
proven  by  clinical  experience.  External  faradism  may  also 
be  employed.  The  object  is  twofold — to  diminish  the  work 
required  of  the  gastric  muscle  and  to  keep  the  muscle 
more  than  equal  to  its  work. 

The  next  object  is  to  aid  and  to  protect  the  intestines, 
thus  securing  and  maintaining  digestive  compensation.  The 
abdomen  should  be  carefully  guarded  by  proper  clothing 
against  extremes  and  changes  of  external  temperature.  The 
food  should  be  finely  divided,  digestible,  and  utilizable,  freshly 
prepared  and  sterilized  ;  no  coarse,  irritating  food  or  drinks, 
and  no  food  liable  to  ferment  or  to  putrefy.  The  same  policy 
of  careful  protection  of  the  intestines  should  extend  to  drugs 
— no  irritants,  nothing  to  disorder  digestion,  no  purgatives, 
and  particularly  no  salines.  The  bowels  should  be  regulated 
by  the  diet,  intestinal  massage,  electricity,  and  the  employ- 
ment of  small  laxative  rectal  injections. 

The  work  of  the  intestines  may  sometimes  be  lightened  by 
the  employment  of  pancreatin  and  a  little  soda  or  a  fresh  ex- 


GASTRITIS.  441 

tract  of  pancreas.  Papoid  sometimes  helps.  The  administra- 
tion of  hydrochloric  acid  and  pepsin,  contrary  to  what  might 
theoretically  be  expected,  does  no  good.  Chemical  treat- 
ment would  seem  to  be  strongly  indicated,  and  theoretically 
this  is  so.  Give  pepsin  and  hydrochloric  acid,  and  give  them 
in  sufficient  quantities  to  replace  the  stomach's  lost  digestive 
power,  is  the  plausible  rule  of  practice.  Our  experience  with 
this  method  forces  us  to  oppose  it  obstinately.  In  some  cases 
it  does  no  very  obvious  harm,  but  it  does  not  relieve  the  sub- 
jective symptoms,  if  they  exist;  it  sometimes  excites  discom- 
fort; it  does  not  improve  nutrition;  but  it  often  disturbs  in- 
testinal digestion  ;  it  often  increases  intestinal  putrefaction  and, 
consequently,  auto-intoxication ;  it  arrests  ptyalin  digestion 
in  the  stomach  ;  and  it  irritates  the  vulnerable  mucous  mem- 
brane. If  chemical  treatment  is  to  be  employed  it  is  better 
to  give  pancreatin  and  a  little  soda,  a  fresh  extract  of  pan- 
creas, or  a  vegetable  ferment. 

The  patient  should  be  as  well  nourished  as  possible,  and 
under  no  circumstances  should  an  insufficient  diet  be  pre- 
scribed. The  disease  is  in  the  stomach,  but  a  danger  is  in 
starvation. 

The  diet  is  selected  by  the  stomach,  by  the  needs  of  nutri- 
tion, and  chiefly  by  the  intestines.  It  is  the  intestines  which, 
in  this  disease,  have  all  the  food  to  digest  and  utilize.  The 
food  should  be  easily  evacuated  by  the  stomach,  digestible 
and  utilizable  by  the  intestines,  and  sufficient  to  supply  the 
demands  of  the  body  for  nutriment. 

The  food  should  be  all  very  finely  divided,  fresh,  and  nutri- 
tious. Sterilized  milk,  if  well  borne,  and  the  fermented  pre- 
parations of  milk  are  suitable.  The  cereals — rice  and  the 
preparations  of  wheat  and  of  Indian  corn  are  the  best — should 
be  cooked  all  to  pieces.  Only  bread  thinlysliced  and  browned 
through  and  through  should  be  permitted.  Expressed  meat 
juice,  meat  broths  (small  quantity),  or  clear  vegetable  soup 
(either  may  be  thickened  with  a  thoroughly  cooked  cereal), 
meat  powder,  and  lean,  short-fibered  fish  are  well  borne. 
The  lean  pulp  (Enterprise  chopper,  old  pattern)  of  the 
fresh  meats  and  fowl  and  game — beef,  mutton,  chicken, 
white  meat  of  turkey,  quail,  etc. — may  be  made  into  cakes 
and  broiled  with  a  little  butter.  Eggs  often  disagree,  par- 
ticularly when  much  of  the  yolk  is  eaten.  Spinach,  string 
beans,  and  fresh  garden  peas  should  be  thoroughly  cooked 
and  passed  through  the  colander  or  sieve.  The  juice  of  a 
ripe  orange,  or  of  a  few  grapes,  or  a  baked  apple  may  some- 
times be  permitted.     Fresh  butter,  and  cream,  and  breakfast 


442  DISEASES  OF  THE  STOMACH. 

bacon  are  the  best  forms  of  fat.  Cod-liver  oil  is  suitable  if  it 
agrees.  Coffee,  very  weak  tea,  "  vigor  chocolate,"  some- 
times cocoa,  and  plain  water  usually  also  agree  very  well. 
From  this  list  a  mixed  and  supporting,  or  even  restorative, 
diet  may  be  selected. 

When  inanition  or  anemia  begins  rest  should  be  ordered 
to  diminish  the  requirements  of  nutrition,  and  the  diet  should 
be  supplemented  by  rectal  feeding.  Every  effort  must  be 
made  to  maintain  the  volume  and  richness  of  the  blood,  and 
an  intestinal  complication  should  receive  prompt  treatment. 

Briefly  stated,  the  chief  indications  to  be  met  in  the  man- 
agement of  chronic  atrophy  of  the  gastric  glands  are : 
(i)  Protect  the  stomach  against  all  mechanical  and  chemical 
irritation ;  (2)  preserve  and  strengthen  and  favor  its  motor 
function;  (3)  maintain  intestinal  digestive  compensation ;  (4) 
maintain  the  nutrition  of  the  body,  the  composition  of  the 
blood,  and  the  tone  and  strength  of  the  neuromuscular  sys- 
tems. 


CHAPTER  IL 

ULCER  OF  THE  STOMACH. 

Ulceration  of  the  gastric  mucosa  ma\- occur  as  an  episode 
in  the  evolution  of  acute  and  chronic  gastritis  and  during  the 
course  of  neoplasms  of  the  stomach.  The  mucous  membrane 
maybe  studded  with  punctate  erosions;  or  there  may  be  small 
ulcers  of  the  size  of  the  head  of  a  pin  which  e.xtend  into  or 
through  the  mucosa;  or  there  may  be  superficial  and,  rarely, 
deep  ulcers  running  along  the  course  of  obliterated  blood- 
vessels. The  formation  of  the  erosions  of  gastritis  may  often 
be  revealed  by  the  little  exfoliations  or  sloughs,  which  are 
rarely  larger  than  i  of  an  inch  in  diameter,  and  which 
are  most  readily  found  in  the  early  morning  lavage  water. 
The  neoplasms  of  the  stomach  may  also  ulcerate.  Insignifi- 
cant or  profuse  hemorrhages  may  accompany  these  forms  of 
secondary  ulceration.  Primary  ulceration  may  occur  as  a 
local  bacterial  infection  in  anthrax,  in  tuberculosis,  and  in 
syphilis.  Tubercular  ulceration  of  the  stomach  is  rare,  and  is 
accompanied,  as  a  rule,  by  pulmonary  or  intestinal  tubercu- 
losis. We  have  been  able  to  collect  only  23  authentic  cases. 
Syphilitic  ulcer  of  the  stomach  is  also  rare  ;  and,  like  the 


ULCER    OF   THE   STOMACH.  443 

tubercular  ulcer,  it  is  a  postmortem  discovery,  and  is  conse- 
quently of  no  great  interest  to  the  physician.  Such  is  not, 
however,  the  case  with  simple  ulcer  of  the  stomach. 

Ulcer  of  the  stomach  is  an  anatomical  disease,  characterized 
by  a  sharply  limited  defect  of  the  mucous  membrane,  distinct 
in  its  genesis,  its  form,  and  its  evolution.  The  disease  has 
been  given  many  other  names  descriptive  of  some  striking 
peculiarity  or  embodying  a  theory  of  its  genesis — simple, 
round,  chronic,  perforating,  corrosive,  rodent,  hemorrhagic, 
peptic. 

The  most  frequent  functional  sign  is  digestive  hydrochloric 
superacidity,  but  this  sign  is  neither  constant  nor  characteris- 
tic. As  a  clinical  entity  it  is  a  modern  disease,  and  is  charac- 
terized in  its  typical  form  by  gastric  pain,  by  hemorrhage,  and 
by  vomiting.  These  cardinal  symptoms  are  not  constant,  and 
are  characteristic  only  when  possessing  a  number  of  distinc- 
tive features.  Beneath  the  play  of  expression  the  unity  of  the 
disease  is  preserved  by  the  gross  anatomical  and  microscopic 
characters  of  the  localized  destruction  of  the  mucous  mem- 
brane, tending  to  go  deeper  and  to  involve  the  other  layers. 

Frequency. — The  frequency  of  gastric  ulcer  varies  in  dif- 
ferent parts  of  the  world.  Most  English  and  American 
authors  state  that  in  about  5  per  cent,  of  deaths  from  all 
causes  an  ulcer  or  an  ulcer  scar  can  be  found.  According  to 
Lebert,  in  about  4  per  cent,  of  the  autopsies  made  in  middle 
Europe  either  an  open  ulcer  or  a  cicatrix  is  found.  Of  41 ,688 
cases  treated  in  the  clinics  of  Zurich  and  of  Breslau  by  Lebert, 
about  0.6  per  cent,  had  gastric  ulcer.  In  hospital  practice 
McCall  Anderson  met  with  35  cases  of  ulcer  in  2538  medical 
cases,  or  about  i  in  73.  The  statistics  of  autopsies  collected 
by  others  give  important  variations  from  these  percentages — 
for  instance,  Dahlaup  (Copenhagen),  13  per  cent.;  Nolte 
(Munich),  1.23  percent.;  Waldeyer  (Breslau),  1.6  per  cent.; 
Lebert  (Breslau),  2.5  per  cent.;  Jaksch  (Prag),  3.2  per  cent.; 
Jaworski  and  Korczynski  (Krakow),  0.24  per  cent. ;  Hauser 
(Erlangen),  3.4  per  cent.;  Steiner  (Berlin),  3.6  per  cent.; 
Berthold  (Berlin),  2.7  per  cent.;  Starke  (Jena),  10  per  cent. 
Age,  sex,  occupation,  diet,  and  the  prevalence  of  gastric 
troubles  associated  with  excessive  secretion  may  explain  the 
differences  of  the  statistics.  The  personal  equation  of  the 
pathologist  doubtless  also  comes  into  play,  some  searching 
with  greater  interest  and  care  for  small  ulcer  scars.  Cases 
are  likely  to  be  included  in  the  statistics  where  the  stomach 
was  not  carefully  examined.     In  a  large  private  practice,  con- 


444 


DISEASES  OF  11  IE  STOMACH. 


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ULCER    OF   THE   STOMACH.  445 

sisting  almost  exclusively  of  patients  with  gastric  and  intes- 
tinal diseases,  we  have  found  simple  ulcer  in  about  i  in  134 
cases. 

Of  the  618  deaths  from  ulcer  in  New  York  City  (see  Table) 
during  the  decad  1 887  to  1 896,  306  were  male  and  312  were  fe- 
male. As  regards  the  age  at  which  death  occurred,  97  were 
under  twenty-five  years;  231  were  between  twenty-five  and 
forty-five  years;  219  were  between  forty-five  and  sixty-five 
years  (or  450  between  twenty-five  and  sixty-five  years) ;  and 
71  were  between  sixty-five  and  eighty-five  years. 

Average   number  of  deaths    Average    number   of  deaths 
Average  population  of  N.  Y.        annually  from  all  causes,  ainiually,     from     ulcer, 

City  for  decad  1887-1896.  1S87-1S96.  1887-1S96. 

1,781,301  41,738  62 

Population  N.  Y.  City,  1896.     Total    deaths,    N.   Y.   City,     Deaths    from    ulcer,     N.  Y. 

1896.  City,  1896. 

1,934,972  40,557  81 

According  to  these  statistics,  i  in  every  763  of  the  total 
deaths  (i 887-1 896),  or  i  in  every  500  of  the  total  deaths 
(1896),  is  due  to  ulcer  of  the  stomach;  or  i  in  every  28,730 
living  inhabitants  (i 887-1 896),  or  i  in  every  23,888  living  in- 
habitants (1896).  The  death-rate  of  ulcer,  like  that  of  cancer 
(Bryant),  is  increasing  from  year  to  year.  The  increase  is 
not  due  to  accident,  or  to  worse  methods  of  treatment,  or  to 
the  greater  and  greater  frequency  of  ulcer;  but  the  increasing 
death-rate  may,  in  all  probability,  be  explained  by  greater 
accuracy  of  death  reports. 

Etiology. — The  occurrence  of  gastric  ulcer  is  in  close  rela- 
tion with  the  age,  some  periods  of  life  being  remarkably  free 
from  the  disease  and  others  conspicuous  on  account  of  its 
frequency.  Certainly,  these  variations  can  not  be  attributed  to 
the  influence  of  age  itself,  but  are  due  to  the  prevalence  at 
certain  periods  of  life  of  the  many  predisposing  causes  more 
closely  connected  with  the  genesis  of  the  trouble. 

Simple  gastric  ulcer  is  very  rare  before  the  tenth  year. 
This  exemption  may  be  due  in  part  to  the  diet,  to  the  rarity 
of  chronic  disease  of  the  stomach  accompanied  by  the  secre- 
tion of  an  excessively  active  and  acid  gastric  juice,  to  healthy 
arteries,  and  to  the  great  resistant  and  reparative  powers  of 
the  young.  It  is  also  supposed  by  some  that  an  ulcer,  should 
it  occur,  would  likely  remain  latent,  and  heal  rapidly  under 
the  influence  of  the  bland  diet  employed  in  the  digestive  dis- 
orders of  infancy  and  childhood.  But  autopsies  made  on 
children  before  the  tenth  year  reveal,  with  comparative  rare- 
ness, either  an  ulcer  or  an  ulcer  scar. 


44^  DISEASES  OF  THE  STOMACH. 

In  drawing  conclusions  from  statistics  showing  the  relation 
of  age  to  the  genesis  of  simple  ulcer  of  the  stomach,  errors 
are  likely  to  be  made.  Evidently,  the  cases  where  only  cica- 
trices are  found  must  be  deducted  from  the  statistics  of  autop- 
sies, for  the  time  when  the  ulcer  or  its  scar  is  found  does 
not  represent  the  date  of  its  commencement.  One  of  the 
clinical  characteristics  of  ulcer  is  its  chronicity,  and  the 
ulcer  or  its  scar  may  be  unexpectedly  discovered  postmortem 
a  long  period  after  its  beginning.  If  death  be  due  to  the 
ulcer,  and  the  clinical  history  be  known,  still,  the  early  period 
may  have  been  entirely  latent.  After  the  correction  of  the 
statistics  it  will  be  found  that  more  than  one-half  of  the  cases 
begin  between  twenty  and  thirty,  and  about  four-fifths  be- 
tween twenty  and  forty.  About  nine-tenths  of  the  deaths 
from  gastric  ulcer  occur  between  twenty  and  sixty,  but  the 
period  of  greatest  mortality  is  between  forty  and  sixty.  After 
the  sixtieth  year  the  frequency  and  the  mortality  are  low,  as  few 
cases  which  began  at  the  age  when  the  disease  predominates 
are  brought  over  and  credited  to  the  later  period.  Ulcer  in 
old  age  is  a  very  fatal  disease,  on  account  of  the  low  healing 
power  when  life's  course  is  nearly  run  ;  but  it  is  not  a  frequent 
disease,  possibly  on  account  of  the  low  hydrochloric  acidity 
of  the  gastric  juice. 

Simple  ulcer  of  the  stomach  is  more  frequent  in  the 
female  than  in  the  male,  but  the  statistics  taken  in  different 
localities  at  different  times  give  inconstant  results.  This  is 
very  apparent  in  the  statistics  of  Lebert.  Of  the  41,688 
patients  treated  in  the  clinics,  21,020  were  men  (69  cases)  and 
20,688  women  (183  cases).  According  to  these  figures,  the 
disease  is  nearly  three  times  more  frequent  in  women  (0.32 
per  cent,  to  o  88  per  cent.).  In  Breslau  the  proportion  is  i 
to  3.5,  but  in  Zurich  it  is  3  to  4,  in  favor  of  its  predominance 
in  women.  McCall  Anderson,  in  his  statistics  of  2538  medi- 
cal cases,  of  which  927  were  women  and  161 1  men,  records 
that  32  of  the  35  cases  of  ulcer  occurred  in  women  (i  in  29) 
and  3  in  men  (i  in  537).  Most  authors,  including  Brinton, 
give  the  proportion  as  about  i  to  2,  but  Steiner  says  8  to  1 1, 
and  Willigk  proposes  i  to  3  in  favor  of  its  greater  frequency 
in  women.  After  the  fiftieth  year  ulcer  is  more  frequent  in 
men  than  in  women.  Many  circumstances  may  explain  the 
differences  in  the  statistical  reports;  such  as  age,  occupation, 
constitution,  diet,  and  the  predominance  in  women  of  certain 
diseases  which  act  as  predisposing  causes  of  ulcer,  such  as 
gastroptosis,  hysteria,  and  chlorosis.  Ulcer  is  more  frequent 
in   hysteria  and    less   frequent    in   chlorosis  (one   per  cent., 


ULCER    OF   THE   STOMACH.  447 

Hayem)  than  is  popularly  believed.  Rasmussen  claims  that 
tight  lacing  produces  a  furrow  across  the  stomach  beneath 
the  edge  of  the  right  costal  border,  and  he  states  that  ulcer 
develops  frequently  along  this  furrow.  Some  predisposing 
diseases  are  more  frequent  in  men — e.  g.,  arteriosclerosis  and 
hypersthenic  gastritis.  It  is  difficult  to  estimate  the  exact 
influence  of  sex,  but  clinical  'and  postmortem  observation 
establishes  the  greater  frequency  of  the  disease  in  women. 

Occupation  and  the  social  and  financial  condition  seem, 
directly  or  indirectly,  to  exert  an  influence  in  the  causation  of 
ulcer.  It  is  well  known  that  the  disease  is  frequent  in  cooks, 
supposably  on  account  of  the  pernicious  habit  of  tasting  hot 
dishes,  of  irregular  eating,  and,  possibly,  on  account  of  reflex 
secretion,  and  of  the  presence  in  the  stomach  of  a  quantity 
of  uncombined  acid.  A  delayed  dinner  in  this  way  often 
produces  a  gastric  headache.  Cooks  are  often  affected  with 
adenohypersthenia,  a  favorable  condition  for  the  develop- 
ment of  ulcer  in  conjunction  with  a  local  disturbance  of  cir- 
culation and  of  nutrition.  Traumatism,  associated  or  con- 
nected with  the  occupation,  is  a  causative  influence,  much 
more  frequently  active  than  is  commonly  believed.  House 
girls  are  more  subject  to  gastric  ulcer  than  is  any  other  class, 
since  they  are  so  often  anemic  or  chlorotic,  and  suffer  from 
menstrual  disorders.  The  disease  is  much  more  frequent 
among  household  servants  than  among  the  rich,  with  the 
exception  of  the  clinical  form  of  ulcer  developing  in  the 
anemic  girl  and  proving  rapidly  fatal  by  perforation.  It  is 
rare  among  those  who  live  and  work  in  the  open  air,  and 
who  eat  largely  a  vegetable  diet.  The  disease  is  almost 
unknown  in  parts  of  Russia,  in  the  Rhone  Valley,  and 
among  the  Bavarian  Alps,  inhabited  by  a  poor  peasantry  who 
rarely  get  an  opportunity  to  taste  meats  or  highly-sweetened 
articles  of  food.  Yet  the  disease  is  very  rare  among  the 
negro  field-laborers  of  the  South,  who  live  on  cornbread, 
molasses,  and  bacon.  The  character  of  the  diet  is  without 
influence  in  the  production  of  the  disease,  unless,  in  com- 
bination with  other  factors,  it  engenders  chronic  hypersthenic 
gastritis.  Alcoholism  and  iced  drinks  have  not  the  etio- 
logical influence  often  attributed  to  them.  Ulcer  respects  no 
class,  nor  condition,  nor  vocation,  but  develops  most  fre- 
quently in  those  who  are  predisposed  to  local  disturbances  of 
the  circulation  or  to  a  local  trophic  defect;  and  it  compli- 
cates most  often  the  diseases,  local  or  general,  which  are 
accompanied  by  a  richly  acid  gastric  secretion. 

Age,  sex,  occupation,  diet,  and  the  social  and  financial  con- 


44^  DISEASES  OF  THE  STOMAL'//. 

dition  are  only  predisposing  causes.  More  directly  and  closely 
related  to  the  genesis  of  the  ulcer  are  certain  cardiovascular 
diseases,  diseases  of  the  blood,  infectious  diseases,  and  diseases 
of  the  stomach. 

The  influence  of  diseases  of  the  heart  and  the  blood-vessels 
is  unquestionable,  ulcer  being  often  the  consequence  of 
arteriosclerosis,  embolism,  thrombosis,  hemorrhagic  infarct, 
and  intense  local  inflammation.  The  circulation  of  a  circum- 
scribed area  is  thus  cut  off,  resulting  in  local  death,  and  in 
the  digestion  of  the  dead  tissue.  It  has  long  been  claimed, 
both  on  clinical  and  anatomical  grounds,  that  chronic  ulcer 
may  be  caused  by  a  local  disease  of  a  blood-vessel  of  the 
stomach.  This  may  occur  in  arteriosclerosis,  in  the  diseases 
of  the  red  corpuscles,  in  syphilis,  and  such  other  diseases  as 
produce  inflammatory  or  degenerative  changes  of  the  arteries. 
As  a  result  of  the  fatty  degeneration  of  the  arterial  wall,  of  a 
small  aneurysm,  of  arteriosclerosis,  or  of  endarteritis,  a  small 
arterial  branch  becomes  plugged  or  obliterated,  and  the  area 
of  the  mucosa  fed  by  this  small  artery  dies  and  is  cast  off  or 
digested,  leaving  an  ulcer  of  the  peculiar  shape  and  form  of 
chronic  ulcer  of  the  stomach.  This  explanation  of  the 
genesis  of  ulcer  has  been  ably  defended  by  Virchow  and 
others.  It  is  denounced  by  some  pathologists  on  the  grounds 
that  ulcer  is  rare  in  old  age,  when  arterial  disease  is  frequent ; 
that  it  is  frequent  before  the  age  of  forty,  when  disease 
of  the  arteries  (non-syphilitic)  is  rare;  that  ulcer  occurs  fre- 
quently when  there  is  no  disease  of  the  arteries  ;  that  diseases 
of  the  arteries  exist  so  frequently  without  an  ulcer  forming 
throughout  their  long  course  ;  that  arteriosclerosis  may 
produce  atrophic  gastritis  without  causing  an  ulcer.  These 
facts  should  be  given  their  due  weight ;  but  it  is  not  claimed 
that  all  ulcers  are  produced  by  arterial  disease,  and  it  is 
known  that  some  gastric  ulcers  are  caused  in  this  manner. 
The  obliteration  of  a  small  artery,  be  it  due  to  disease  of  its 
walls,  to  embolism,  to  thrombosis,  or  to  a  node-like  and 
intense  inflammatory  infiltration  and  compression,  may  be  the 
cause  of  ulcer,  just  as  a  hemorrhagic  infarct  may  produce 
the  death  of  a  circumscribed  part  of  the  muco.sa  which  lies 
over  it.  Ulcer  is  not  a  disease  with  a  single  cause  and  one 
mode  of  genesis,  as  is  often  assumed. 

The  etiological  influence  of  the  diseases  of  the  blood  is 
questioned  by  man)'  authors,  who  consider  the  blood  changes 
secondary.  It  is  doubtless  true,  if  the  evidence  of  close  clini- 
cal study  is  trustworthy,  that  the  anemia  is  often  hemorrhagic 
or  due  to  inanition,  the  ulcer   being  primary,  but  prevented 


ULCER    OF   THE   STOMACH.  449 

from  healing  by  the  dystrophic  influence  of  the  thin  blood. 
This  is  well  shown  by  the  evolution  of  the  anemia  and  by  its 
rapid  cure  by  controlling  the  hemorrhage  and  the  inanition. 
That  a  supposed  primary  anemia  may  be  the  consequence  of 
a  latent  ulcer  is  also  a  possibility.  It  is  equally  certain  that 
the  anemia  is  often  primary  and  causative,  or  is  a  coeffect. 
The  existence  of  chlorosis  can  be  explained  only  as  a  coinci- 
dence or  as  a  cause,  for  neither  hemorrhage  nor  inanition 
will  produce  it,  and  ulcer  is  far  more  frequent  in  chlorosis 
than  in  oligocythemia.  The  diseases  of  the  blood  are  sup- 
posed to  act  by  producing  a  local  arterial  spasm  or  fatty 
degeneration  of  the  arterial  walls.  Hydrochloric  super- 
acidity  is  not  rare  in  chlorosis,  and  could  at  least  make  the 
genesis  of  the  ulcer  easier.  It  may  be  taken  as  a  clinical  fact 
that  oligocythemia  and  chlorosis  may  aid  in  the  generation 
and  often  play  a  predominant  part  in  the  persistence  of  ulcer. 

It  has  been  maintained  by  some  that  ulcer  is  a  specific 
process,  and  bacteriology  has  been  called  upon  to  reveal  the 
unique  cause.  That  ulcer  may  result  from  an  infectious  disease 
seems  established  by  clinical  observation  and  by  experimental 
pathology.  Cases  have  been  reported  following  diseases 
associated  in  their  evolution  withpus  formation  or  the  pro- 
duction of  hemorrhagic  infarcts  or  thrombi,  and  the  patho- 
genic bacteria  have  been  found  in  the  blood-vessel  where  the 
necrotic  process  was  localized  (LetuUe).  Puerperal  fever, 
typhoid  fever,  endocarditis,  abscess,  suppurative  peritonitis, 
pleurisy,  tuberculosis,  and  syphilis,  among  other  infectious 
diseases,  have  been  mentioned  in  this  connection.  It  may 
be  admitted  that  gastric  ulcer  may  be  produced  by  infec- 
tion through  the  circulation.  The  presence  of  bacteria  in  the 
walls  of  the  ulcer  (Boettcher)  can  only  be  considered  accidental 
and  secondary. 

The  pathogenic  influence  of  hydrochloric  superacidity  is 
still  a  matter  of  dispute.  Some  pathologists  make  this  con- 
dition essential,  and  claim  that  without  it  ulcer  does  not  occur, 
or,  at  least,  that  no  cases  which  contradict  this  hypothesis 
have  yet  been  reported  which  do  not  admit  of  explanation 
by  the  well-known  intermittent  course  of  the  diseases  or  the 
affections  of  the  stomach  accompanied  by  excessive  secretion. 
The  theory  is  seductive  in  its  simplicity — a  very  active  and 
superacid  secretion,  a  diminution  of  the  vitality  of  a  localized 
area  of  the  mucous  membrane,  autodigestion  and  a  resulting 
circumscribed  defect  of  the  mucous  membrane,  the  repair  of 
which  is  delayed  or  prevented  by  the  irritation  or  the  action 
of  the  strongly  acid  gastric  juice.  But  if  its  parts  be  more 
29 


450  DISEASES  OF  THE  STOMACH. 

closely  examined,  it  would  seem  that  the  theory  is  too  ex- 
clusive. 

There  is  no  evidence  to  prove  that  excessive  hydrochloric 
acidity  always  precedes  the  development  of  ulcer.  Simple 
adenohypersthenia  (a  dynamic  affection)  is  rarely  complicated 
by  an  ulcer;  it  is,  however,  different,  as  we  have  seen,  with 
hypersthenic  ijastritis.  It  is  a  fact  of  which  we  have  no 
doubt  that  ulcer  may  run  its  entire  course  without  excessive 
hydrochloric  acidity,  and  where  the  excessive  secretion  is 
not  suppressed  by  hemorrhage,  weakness,  inanition,  or 
anemia.  When  in  the  course  of  treatment  these  symptoms 
disappear,  the  excessive  secretion  does  not  return.  The 
hyperchlorhydria  often  disappears  permanently  with  the  cure 
of  the  ulcer,  suggesting  at  least  the  possibility  of  its  having 
been  excited  in  a  manner  probably  analogous  to  the  exces- 
sive lachrymal  secretion  in  a  corneal  ulcer,  or  that  its  cause 
(ulcer,  or  not)  was  removed  by  the  ulcer  treatment.  That  it 
is  not  alone  an  efficient  cause  is  proven  by  the  whole  mucous 
membrane  not  being  involved,  and  by  cases  of  hyperchlor- 
hydria running  a  long  course  without  ulcer  being  generated, 
even  after  injury  of  the  mucous  membrane  by  the  use  of  the 
tube.  In  about  70  per  cent,  of  the  cases  of  ulcer  there  is 
hydrochloric  superacidity.  In  the  remainder  of  the  cases 
secretion  is  normal,  or  there  may  be  hypochylia,  or,  very 
rarely,  even  achylia.  The  hydrochloric  superacidity  may 
have  preceded  the  ulcer;  it  may  have  followed  the  ulcer 
(obstruction  of  pylorus,  etc.) ;  or  it  may  be  the  irritative 
expression  of  the  ulcer.  It  would  not  be  right  to  assume 
that  at  the  moment  when  the  ulcer  developed  there  was 
not,  in  any  of  a  series  of  cases,  hyperchlorhydria,  but  it 
is  not  highly  probable  that  a  temporary  hyperchlorhydria 
would  produce  an  ulcer.  Moreover,  ulcer  is  not  situated  most 
frequently  where  the  gastric  secretion  is  most  acid  nor  most 
in  contact  with  the  mucous  membrane;  but  where  all  ana- 
tomical alterations  of  the  mucous  inenibrane  are  most  frequent 
and  most  intense.  Nor  can  it  be  admitted  that  the  occurrence 
of  this  peculiar  form  of  ulcer  only  in  the  stomach  and  in  the 
digestive  tube  close  to  it,  is  proof  that  the  gastric  juice  has 
anything  to  do  with  its  causation.  Certainly,  peptic  ulcer  can 
not  be  produced  by  autodigestion  alone. 

Autodigestion  is  prevented,  not  by  mucus,  not  by  the 
alkaline  blood  nor  by  active  absorption,  but  by  the  resist- 
ance of  the  living  protoplasm  of  the  cell.  The  mucus  does 
not  prevent  postmortem  digestion  nor  the  peptonization 
of  meat  coated  by  it.     The  gastric  juice  is  secreted  beneath 


ULCER    OF   THE   STOMACH.  45  I 

the  mucus,  and  does  not  digest  a  part  of  the  mucous  mem- 
brane which  is  kept  free  from  mucus.  Erosions  heal  and 
cells  are  regenerated  in  the  presence  of  the  gastric  juice. 
Germs  live  in  it.  Ferment-producing  organisms  do  not 
digest  themselves,  and  the  blood  and  the  tissues  of  the  body 
destroy  ferments.  The  action  is  not  prevented  by  the  alkaline 
blood,  for  the  HCl  secreted  by  and  in  the  cell  is  not  neutral- 
ized;  the  pancreatic  juice  does  not  digest  the  intestines,  nor 
does  papain  digest  either  an  acid  or  an  alkaline-reacting  liv- 
ing tissue.  Autodigestion  is  possible  only  where  the  proto- 
plasm of  the  cell  no  longer  possesses  its  normal  properties 
and  powers  of  resistance. 

Though  excessive  hydrochloric  acidity  is  not  a  necessary 
factor  in  the  genesis  of  ulcer,  it  can  not  be  doubted  that  it  is 
often  a  pathogenic  power  of  great  importance,  and  often  ex- 
erts a  pernicious  influence  on  the  persistence  of  the  trouble ; 
and  its  control  is  a  commanding  indication  in  the  treatment. 
Where  the  excessive  secretion  is  a  symptom  of  hypersthenic 
gastritis,  the  condition  exists  most  favorable  to  the  genesis  of 
ulcer  ;  the  node-like  and  limited  infiltration  of  the  mucous 
membrane  or  submucosa  being  often  sufficient  to  reduce  the 
circulation  and  nutrition  of  a  local  area  of  the  mucous  mem- 
brane so  low  as  to  render  it  unable  to  resist  the  digestive 
power  of  the  excessively  acid  and  very  active  gastric  juice. 

Etiologically,  ulcer  is  primarily  dystrophic,  the  essential 
conditions  of  its  genesis  being  the  local  defect  of  the  circula- 
tion and  of  the  nutrition  in  a  part  exposed  to  the  digestive 
action  of  a  gastric  juice  usually  excessively  acid.  The  defect 
is  made  persistent  by  the  diminished  reparative  powers  of  the 
organism,  and  by  local  irritations  intimately  associated  with 
the  functions  of  the  stomach.  The  etiology  gives  the  com- 
manding indications  in  treatment — functional  rest,  protec- 
tion, and  the  improvement  of  nutrition. 

Pathological  Anatomy. — Simple  ulcer  of  the  stomach  is 
usually  single,  but  in  about  one-fifth  of  the  autopsies  more 
than  one  is  found.  These  may  be  of  different  ages,  or  a  fresh 
ulcer  may  be  found  coexisting  with  an  old  scar.  Sometimes 
two  old  ulcers  are  found  corresponding  with  the  areas  sup- 
plied by  two  branches  of  a  small  artery  (obstructed),  which 
later  unite  to  form  one  irregularly  shaped  ulcer.  Conse- 
quently, a  single  ulcer  or  a  single  scar  found  at  the  autopsy 
may  represent  the  union  of  two  ulcers  distinct  in  their  earlier 
stages.  Two,  three,  four,  five,  or  even  more  may  coexist,  and 
may  vary  in  form,  in  size,  and  in  age.  But  cases  of  multiple 
peptic  ulcers  exhibiting  these  characteristics  are  rare. 


452  DISEASES  OF  THE  STOMACH. 

Ulcer  shows  a  decided  preference  for  certain  rejjions  of 
tlie  stomach.  The  favorite  localities  are  the  smaller  curva- 
ture, the  posterior  wall,  and  the  pyloric  region.  The  portions 
most  frequently  affected  are  a  small  area  of  the  posterior  sur- 
face near  the  pylorus,  and  another  along  the  lesser  curvature. 
Often  one  is  located  on  the  lesser  curvature,  and  another  close 
by  on  the  posterior  wall.  Rarest  in  the  fundus,  it  is  much  less 
frequent  on  the  anterior  wall,  in  the  cardiac  region,  and 
along  the  greater  curvature  than  over  the  favorite  localities. 
About  half  the  cases  occur  in  the  p}'loric  third  of  the  stom- 
ach. A  plane  passing  vertically  through  the  cardiac  orifice 
and  the  tip  of  the  cartilage  of  the  left  tenth  rib  would  locate 
about  four-fifths  of  the  ulcers  to  its  right.  Brinton  gives  the 
following  percentages:  Posterior  surface,  43  per  cent.; 
lesser  curvature,  27  per  cent.;  pyloric  extremity,  16  per 
cent.;  anterior  and  posterior  surfaces,  6  per  cent.;  anterior 
surface,  5  per  cent.;  greater  curvature.  2  per  cent.  Welch 
locates  more  on  the  lesser  curvature  (36  percent.)  than  on  the 
posterior  wall  (30  per  cent.),  and  Lebert  gives  nearly  the  same 
percentage  (33  per  cent.)  for  the  lesser  curvature  as  does 
Welch. 

The  typical  peptic  ulcer  is  round  or  oval,  but  this  form  is 
by  no  means  constant.  The  borders  commonly  run  in 
regular  curves,  but  the  coakscence  of  adjacent  ulcers  may 
produce  a  variety  of  shapes.  A  comma  shape  is  not  rare, 
and  the  pylorus  may  be  partly  or  completely  surrounded  by 
a  ring.  A  marked  characteristic  is  the  arrangement, of  the 
long  axis  of  the  ulcer  in  the  direction  of  the  obliterated 
artery,  the  area  of  the  distribution  of  which  corresponds  with 
the  form  and  the  extension  of  the  ulcer.  The  size  is  likewise 
very  variable,  the  common  size  being  that  of  a  silver  dime  or 
quarter;  but  some  are  as  small  as  peas,  and, exceptionally, 
the  defect  may  cover  a  space  as  large  as  the  adult  hand. 

The  other  gross  anatomical  characteristics  present  slight 
variations,  dependent,  seemingly,  on  the  age,  the  depth,  and 
the  genesis  of  the  ulcer.  The  borders  marked  by  the 
mucous  membrane  are  usually  perpendicular  or  slightly 
rounded,  and  sometimes  a  little  undermined;  but  t\-pically 
the  appearance  is  that  of  a  defect  left  by  the  removal  of  a 
piece  of  the  mucous  membrane  with  a  round  chisel  gouge. 
The  border  is  usually  uninflamed.  but  may  be  red  and 
swollen,  and  is  sometimes  hard  and  calloused  and  formed  of 
new  connective  tissue.  The  ulcer  may  extend  no  deeper 
than  the  mucous  membrane,  the  bottom  being  smooth  and 
non-granulated.     But   often    the  process   begins  or    extends 


ULCER    OF   THE   STOMACH.  453 

deeper,  and  a  remarkable  appearance  results,  the  ulcer  ex- 
tending obliquely  in  a  funnel  shape,  one  side  of  which,  partic- 
ularly, may  form  a  stairway  descending  to  the  peritoneum, 
the  steps  being  formed  by  the  mucous  membrane,  the  sub- 
mucosa,  and  the  muscular  layer.  But  often  the  descent  is 
gradual,  oblique,  conical,  with  here  and  there  little  projections 
of  connective  tissue.  The  bottom  is  grayish-yellow,  or  is 
composed  of  the  pale  tissue  of  the  layer  to  which  the  ulcer 
extends  ;  or,  it  may  be  occupied  by  a  grayish-black  slough. 
In  complicated  cases  the  tissues  of  an  adjacent  organ, 
particularly  the  pancreas,  may  be  seen  in  the  bottom,  or 
near  the  apex  may  be  visible  the  gaping  blood-vessel 
which  has  caused  the  fatal  hemorrhage. 

The  gross  anatomical  characteristics  of  the  recent  ulcer 
would  suggest  a  defect  produced  by  the  digestion  of  the  dead 
tissue  corresponding  with  the  distribution  of  a  small  arterial 
branch,  without  being  followed  immediately  by  inflammatory 
reaction  or  by  an  effort  at  repair.  But  sooner  or  later  the 
edges,  the  wall,  and  the  base  are  the  seat  of  a  productive  inflam- 
mation. The  early  stage  of  the  ulcer  reveals  its  dystrophic 
nature.  The  inflammation  is  seldom  intense,  but,  exception- 
ally, the  tissues  near  the  ulcer  are  secondarily  invaded  by 
bacteria.  Microscopically,  the  inflammation  about  the  ulcer 
is  productive,  and  presents  the  same  characteristics  as  hyper- 
sthenic gastritis — more  or  less  infiltration  with  embryonic 
cells,  preservation  of  the  chief  cells,  and  decrease  or  increase 
in  number  of  the  border  cells,  and  glandular  proliferation. 
Associated  with  this  local  inflammation  is  often  found  general 
chronic  hypersthenic  gastritis,  more  intense  in  the  pyloric 
region  and  accompanied  by  more  or  less  interstitial  infiltra- 
tion. The  relation  of  this  form  of  inflammation  to  the  genesis 
of  ulcer  has  already  been  discussed. 

The  blood-vessels  in  the  region  adjacent  to  the  ulcer  often 
show  remarkable  changes.  The  process  is  one  of  progressive 
destruction  by  proliferating  endarteritis.  The  capillaries,  the 
venous  radicles,  and  the  arterioles  are  alike  involved,  and  a 
thrombus  composed  of  a  mass  of  white  cells  may  be  seen 
plugging  the  contracted  lumen.  The  wall  of  the  blood- 
vessel is  infiltrated  with  amorphous  matter  and  with  embry- 
onic cells.  The  endothelium  proliferates  and  the  muscular 
coat  undergoes  fatty  degeneration.  In  rare  cases  of  infec- 
tious origin  the  clots  may  contain  pathogenic  bacteria. 
There  can  be  no  doubt  that  this  devascularizing  process  is  a 
protection  against  hemorrhage.  But  the  arterial  wall  may  be 
softened  and  may  yield  to  the  pressure  of  the  blood  before  its 


454  DISEASES  OF  THE  STOMACH. 

lumen  is  obstructed.  The  liemorrhage  may  be  venous,  capil- 
lary, or  (nearly  al\va\'s)  arterial — slow,  continuous,  recurring, 
small,  or  fatal  in  a  few  minutes. 

In  the  majorit}'  of  cases  a  plastic  peritonitis  develops  over 
the  apex  of  the  ulcer.  The  inflammation  is  circumscribed 
and  productive,  the  thickened  peritoneum  being  covered  by 
pseudomembrane,  often  leading  to  the  firm  adhesion  of  the 
stomach  to  adjacent  parts.  Infrequently,  the  peritonitis  extends 
over  a  large  part  of  the  stomach.  The  process  is  a  bung- 
ling effort  at  conservatism,  offering  a  protection  against 
perforation,  but  forming  adhesions  which  impair  the  motor 
functions  of  the  stomach,  and  which,  while  preventing  a  rap- 
idly fatal  purulent  peritonitis,  leads  to  circumscribed  abscesses, 
destruction  of  an  adjacent  organ,  burrowing  of  pus,  pyemia, 
cachexia,  and  usually  death. 

In  about  one-half  the  cases  of  ulcer  the  stomach  is  bound  to 
an  adjacent  part  by  plastic  peritonitis.  On  account  of  the  re- 
lations of  the  parts  of  the  stomach  most  frequently  the  seat  of 
ulcer,  the  adhesions,  in  about  seven-eighths  of  the  cases,  are 
between  the  stomach  and  the  pancreas  or  the  left  lobe  of  the 
liver.  Infrequently,  the  stomach  is  united  with  the  diaphragm, 
the  abdominal  wall,  the  omentum,  the  spleen,  or  the  colon. 
The  adhesions  may  also  be  multiple,  and  often  interfere 
greatly  with  the  churning  and  the  evacuating  movements  of 
the  stomach.  They  may  also  long  remain  sensitive  or  may 
become  the  seat  of  stubborn  neuralgia. 

In  about  five  per  cent,  of  the  cases  the  ulcer  perforates  the 
gastric  wall,  coming  in  contact  with  adherent  adjacent  tissues 
or  producing  encysted  or  general  purulent  peritonitis. 

Perforation  after  adhesions  have  been  formed  is  most  fre- 
quent where  the  ulcer  is  located  on  the  posterior  wall,  near 
the  lesser  curvature,  or  in  the  pyloric  region.  But  the  com- 
paratively rare  ulcers  of  the  anterior  wall  perforate  more  fre- 
quently, and,  on  account  of  the  free  movements  of  this  part 
of  the  stomach,  nearly  always  before  adhesions  have  formed. 
Death  follows  this  accident — rapidly,  from  shock,  or  in  a  few 
days,  from  general  purulent  peritonitis. 

The  opening  in  the  peritoneal  coat  is  small,  varying  in  size 
from  a  pin-head  to  a  pea,  usually  rounded  and  clear-cut,  but 
sometimes  irregular  in  shape  with  ragged  edges.  The  open- 
ing is  made  by  gradual  erosion  or  by  necrosis  and  digestion 
after  the  peritoneal  blood  supply  has  been  cut  off  Increased 
intragastric  pressure  may  be  the  occasion  of  the  perforation. 

Perforation  after  adhesion  with  the  pancreas  brings  the 
resistant  tissue  of  this  organ   into  communication  with  the 


ULCER    OF   THE   STOMACH.  455 

cavity  of  the  stomach  and  its  contents.  In  the  base  of  the 
ulcer  (the  perforation  often  being  large)  may  be  seen  the  red- 
dish-yellow glandular  structure,  interlined  by  the  grayish 
interstitial  framework  of  the  pancreas.  The  destructive  pro- 
cess may  extend  into  the  substance  of  the  gland  and  form  a 
number  of  fistulae,  or  may  open  a  blood-vessel  and  produce  a 
fatal  hemorrhage. 

The  liver  is  much  less  resistant  than  the  pancreas,  and 
purulent  inflammation  destroys  its  substance  rapidly,  leaving 
in  its  stead  a  cavity  containing  pus  and  communicating 
through  a  small  opening  with  the  cavity  of  the  stomach. 
The  perforation  may  open  a  communication  with  the  gall- 
bladder, the  colon,  the  small  intestine,  the  spleen;  with  the 
abdominal  wall,  resulting  in  the  formation  of  a  gastric  fistula; 
with  the  diaphragm,  through  which  pus  may  perforate  and 
invade  the  organs  of  the  thoracic  cavity. 

As  a  consequence  of  perforation  a  generator  localized  puru- 
lent peritonitis  may  be  excited.  The  pathological  anatomy 
is  that  of  perforative  peritonitis.  Subdiaphragmatic  abscess 
results  when  the  affected  area  is  walled  in,  and  is  usually 
located  in  the  left,  but  the  collection  of  pus  may  also  be  found 
in  the  right  (rare),  hypochondrium,  according  to  the  seat  of 
the  perforating  ulcer. 

An  abscess  may  also  be  formed  when  the  perforation  takes 
place  after  adhesions,  the  new  tissue  of  union  yielding  to  the 
ulceration  and  the  abscess  communicating  through  the  small 
opening  with  the  cavity  of  the  stomach.  The  subdiaphrag- 
matic abscess  may  open  into  the  peritoneal  cavity,  or  may 
perforate  the  diaphragm,  the  pleura,  the  pericardium,  the 
heart,  or  may  open  through  the  lung  into  a  bronchus. 

Gastric  ulcer  either  ends  in  perforation,  with  its  disastrous 
consequences,  or  heals,  unless  interrupted  in  its  course  by  a 
fatal  accident. 

The  appearance  and  the  effects  of  the  cicatrix  vary  accord- 
ing to  the  size,  the  form,  the  depth,  and  the  location  of  the 
ulcer.  If  the  ulcer  heals  only  after  the  destruction  of  the 
mucous  coat,  the  depression  marking  the  repaired  defect  may 
be  small  or  only  discoverable  on  close  inspection.  But 
usually  the  scar  is  star-shaped,  with  a  central  mass  of  connec- 
tive tissue  sending  out  in  various  directions  lines  of  fibrous 
tissue  of  variable  length.  The  central  depression  may  be 
formed  of  fibrous  tissue  developing  in  the  organ  or  the  part 
to  which  the  stomach  has  been  united  by  plastic  peritonitis. 
The  organ  is  then  deformed  by  being  drawn  up  in  folds,  and 
a  funnel-shaped  sac  is  created.     The  mucous  membrane  may 


456  D/S EASES  OF  77/ E  STOMACH. 

be  thrown  into  irregular  folds  by  the  contraction  of  the  scar 
tissue. 

Certain  deformities  interfere  in  a  remarkable  manner  with 
the  functions  of  the  stomach.  The  pylorus  may  be  drawn 
almost  against  the  cardia,  the  round  organ  thus  formed 
evacuating  its  contents  with  difficulty.  Or  a  band  may  ex- 
tend transversely  around  the  stomach  and  divide  it  into  two 
cavities  united  by  a  small  opening.  Very  infrequently  the  car- 
dia is  obstructed.  Pyloric  obstruction  is  common,  and  may  be 
due  to  accompanying  inflammatory  swelling  or  to  the  cica- 
trization of  a  pyloric  ulcer.  This  is  a  very  grave  deformity, 
and  about  one-tenth  of  the  deaths  due  to  ulcer  are  produced 
in  this  manner.  Gastric  ulcer  may  heal  perfectly,  or  it  may 
leave  deformities  which  impair  the  functions  of  the  stomach, 
or  which  destroy  life  by  inanition  and  by  auto-intoxication. 

Clinical  Description. — There  is  no  anatomical  disease  of 
the  stomach  the  clinical  e.xpression  of  which  is  more  variable 
than  that  of  gastric  ulcer.  The  clinical  history  is  more  fre- 
quently the  expression  of  the  associations,  the  accidents,  and 
the  com[)lications  than  of  the  ulcer  itself.  The  beginning 
takes  its  predominant  characteristics  from  the  mode  of  action 
and  the  nature  of  the  causes.  The  evolution  is  defined  by 
the  accompanying  gastritis,  hyperchlorhydria,  hyperesthesia, 
peritonitis,  adhesions,  perforation  and  its  consequences,  the 
effects  of  the  deformities  and  of  the  inanition. 

The  anatomical  lesion  constitutes  the  danger,  and  about 
its  origin  and  evolution  gather  the  conditions,  the  accidents, 
and  the  diseases  which  reveal  its  presence.  In  typical  cases 
the  diagnosis  presents  no  difficulty;  in  atypical  cases  it  may 
rest  upon  a  probability  ;  the  latent  form  may  create  no  suspi- 
cion of  its  existence.  It  is  not  possible  at  a  given  moment  to 
say  whether  the  disease  will  terminate  in  a  perfect  cure,  in 
chronic  invalidism,  or  in  death.  The  variable  clinical  expres- 
sion embodied  in  the  modes  of  beginning,  of  evolution,  and  of 
termination  makes  clear  the  variable  etiology,  genesis,  patho- 
logical anatomy,  state  of  nutrition,  and  complications. 

Ulcer  may  have  no  clinical  e.xpression,  and  may  run  its 
entire  course  without  exciting  the  suspicion  of  the  patient  or 
of  the  physician,  ending  in  complete  recovery.  This  is  the 
completely  latent  form,  the  scar  being  found  at  the  autop.sy 
after  death  from  some  other  cause.  If  a  complete  clinical 
history  could  be  obtained  it  would  probably  be  found  that 
the  disease  had  not  run  its  course  in  complete  silence,  but 
that  the  subjective  symptoms  were  not  so  severe  as  to  cause 
the  patient  to  consult  a  physician,  or  were  considered  so  com- 


ULCER    OF   THE   STOMACH.  457 

mon  as  to  be  unworthy  of  notice,  of  mention,  or  of  treatment. 
This  form  is  most  common  among  the  poor,  and  must  be 
ignored  in   the  clinical  description. 

The  subjective  symptoms  may  be  suppressed  during  a  part 
of  the  course  of  the  disease.  These  are  the  purely  anatomi- 
cal periods  in  the  beginning  and  during  the  evolution,  occur- 
ring as  breaks  in  the  progress  of  the  disease,  or  during  the 
period  of  healing,  but  more  frequently  in  the  beginning.  The 
anatomical  periods  create  no  suspicion,  are  deceptive,  and 
induce  a  false  sense  of  security. 

The  period  of  formation  of  the  ulcer  may  be  latent  or 
anatomical.  In  this  mode  of  genesis  the  ulcer  develops 
without  a  symptom.  It  may  represent  a  very  short  period, 
during  which  the  gastric  juice  is  eating  out  the  circumscribed 
dead  or  dying  piece  of  the  gastric  wall.  It  may  be  readily 
understood  why  an  ulcer,  generated  rapidly  after  thrombosis, 
embolism,  or  infarct,  and  unaccompanied  by  gastritis,  by  peri- 
tonitis, or  by  a  complication,  might  not  be  manifested  by  any 
subjective  or  objective  sign.  The  genesis  of  ulcer  in  the 
course  of  an  infectious  disease  may  also  be  concealed,  the 
gastric  symptoms  being  masked  or  misinterpreted,  or  sup- 
pressed by  the  weakness  of  the  organism.  Or,  again,  the 
beginning  may  be  characterized  by  a  few  irregular,  indefinite, 
and,  for  diagnostic  purposes,  meaningless  subjective  and  ob- 
jective signs.  This  anatomical  period  of  invasion  may  end 
suddenly  with  perforation  or  with  profuse  hemorrhage,  or 
may  more  slowly  assume  the  common  clinical  characteristics 
of  ulcer — the  special  pain,  the  vomiting,  the  nervousness,  the 
anemia,  and  the  irritation.  About  one-fourth  of  all  clinically 
recognizable  cases  of  ulcer  develop  in  this  manner. 

In  other  cases  the  clinical  expression  of  the  period  of 
invasion  is  atypical,  and  the  recognition  of  the  disease  is  de- 
pendent on  the  results  of  the  examination.  This  is  the  physi- 
cal mode  of  beginning.  The  patient  complains  of  discom- 
fort, of  flatulency  after  meals,  but  has  no  true  pain  ;  at  times, 
possibly,  a  little  nausea  and  a  poor  appetite  ;  or  there  may 
be  only  headache,  constipation,  and  soreness  in  the  epigas- 
trium. The  subjective  symptoms  are  digestive,  but  have  none 
of  the  definite  characteristics  of  those  typical  of  ulcer.  The 
clinical  history  does  not  suggest  gastric  ulcer,  which  is  re- 
vealed by  the  examination  ;  or  the  examination  marks  the 
case  as  doubtful ;  and  the  efficiency  of  specific  treatment  or 
the  subsequent  developments  of  the  case  confirm  the  sus- 
picion of  an  ulcer.     The  physical  mode  of  beginning  charac- 


458  DISEASES  OF  THE  STOMACH. 

terizes  the  early  period  of  about  one-fourth  of  the   cases  of 
simple  ulcer  of  the  stomach. 

In  one-half  of  the  cases  the  symptoms  of  the  initial  period 
are  those  of  adenohypersthenia  gastrica  or  of  hypersthenic 
gastritis.  The  clinical  description  of  these  diseases  has 
already  been  given.  In  the  majority  of  these  cases  the 
symptoms  of  hyperchlorhydria,  of  hyperch\lia,  or  of  hyper- 
sthenic gastritis  precede  the  development  of  those  charac- 
teristic of  ulcer.  In  a  small  number  of  cases  the  symptoms 
of  ulcer  and  the  accompanying  diseases  seem  to  begin  and 
to  develop  together.  These  diseases,  so  often  found  asso- 
ciated, are,  etiologically,  points  of  the  same  vicious  circle. 
In  this  mode  of  invasion  the  existence  of  the  ulcer  may  be 
revealed  with  certainty  from  the  beginning  by  the  clinical 
history,  standing  in  clear  contrast  to  the  anatomical  and 
the  physical  modes  of  development.  But  in  a  number  of 
cases,  for  a  longer  or  shorter  period,  it  is  impossible  to  ex- 
clude or  to  detect  an  ulcer  accompanied  by  hypersthenic  gas- 
tritis or  by  adenohypersthenia  gastrica. 

The  evolution  of  ulcer  after  it  has  become  a  clinical  disease 
may  be  slow  or  rapid.  Perforation  or  hemorrhage  may  be 
the  first  revealing  sign,  and  either  of  these  accidents  may 
prove  quickly  fatal.  The  rapidly  fatal  perforative  form  is 
most  frequent  in  girls,  who  may  be  thus  suddenly  taken  off  in 
the  bloom  of  youth.  The  hemorrhage  may  at  once  or  after 
several  recurrences  be  fatal ;  or  the  patient  may  recover  from 
the  effects  of  this  accident,  and  the  evolution  of  the  ulcer 
may  continue.  These  rapidly  fatal  cases  are  described  as 
acute,  but  a  quick  termination  by  death  from  a  complication 
should  not  be  considered  a  characteristic  of  the  morbid  pro- 
cess which  is  in  its  nature  essentially  chronic;  The  quickly 
fatal  cases  are  preceded  by  a  longer  or  shorter  anatomical 
period. 

The  evolution  of  ulcer  may  be  short,  and  may  end  within 
S1.X  or  eight  weeks  in  cure  by  cicatrization.  These  are  the 
true  acute  cases;  the  ulcer  beginning  at  a  particular  moment 
(after  traumatism,  for  instance),  manifesting  itself  by  typical 
symiptoms  and  signs,  and,  under  proper  treatment,  disap- 
pearing completely  and  permanently. 

l^ut  this  is  not  the  usual  course,  which  is  slow,  chronic, 
variable,  often  with  exacerbations  and  remissions,  and  with 
certain  symptoms  predominating  and  defining  various  clinical 
forms  of  ulcer.  The  chronic  form  of  ulcer  lasts  a  variable 
time.     The  duration  may  not  exceed  one  or  five  years,  but 


ULCER    OF   THE   STOMACH.  459 

frequently  the  ulcer  remains  unhealed  for  fifteen  or  even 
twenty-five  years.  It  is  the  persistence  of  the  anatomical 
lesion  and  of  its  consequences  during  this  chronic  course 
which  maintains  the  clinical  unity  of  the  disease  beneath 
its  variable  play  of  expression.  The  distinctive  symptoms 
are  the  peculiar  pain,  the  hemorrhage,  and  the  vomiting,  which 
are  associated  with  other  symptoms  occasioned  by  the  func- 
tional activity  of  the  stomach. 

The  early  morning,  when  the  stomach  is  empty  after  the 
night's  repose,  is  the  most  comfortable  moment  for  a  patient 
with  ulcer.  There  is  usually,  before  rising  from  bed,  no  pain 
nor  discomfort,  and  the  appetite  is  commonly  preserved. 
There  may,  however,  be  a  slight  headache,  small  appetite,  or 
dread  of  food,  and  no  refreshment  from  the  broken  sleep  ;  the 
patient  may  be  in  some  cases  worn  out  by  pain,  nervous,  and 
weak.  But  the  early  morning  is  still  the  most  comfortable 
period  of  the  day.  After  breakfast  the  digestive  symptoms 
begin,  variable  in  the  different  cases,  but  in  relation  with  the 
quantity  and  quality  of  food — pain,  heartburn,  acid  eructa- 
tions, relieved  often  by  the  vomiting  of  an  acid  fluid  mixed 
with  food,  or  by  the  passage  of  the  chyme  into  the  intestines. 

During  the  interval  between  the  digestive  periods  the 
symptoms  are  comparatively  quiescent,  but  they  reappear  on 
the  taking  of  food.  In  addition  to  these,  there  may  be  other 
digestive  symptoms,  of  secondary  importance,  and  due  to  the 
state  of  nutrition  and  of  the  nervous  system,  and  to  the 
complications. 

The  Cardinal  Symptoms. — The  genesis  of  the  pain  of 
gastric  ulcer  is  very  complex.  That  the  constitution  and  the 
temperament  of  the  patient  exert  a  great  influence  there  can 
be  no  doubt.  Some  suffer  intensely  ;  others  bear  severe  pain 
with  indifference,  and  are  not  subject  to  neuralgias.  This 
subjective  element  explains  why  in  gastric  ulcer,  with  prac- 
tically the  same  conditions,  the  intensity  of  the  pain  should 
be  so  variable.  Much  depends,  also,  on  the  temporary 
condition  of  the  nervous  system.  All  conditions  accom- 
panied by  increased  irritability  of  the  nerve-centers  sharpen 
the  perception  and  generalize  the  effects  of  the  pain.  Of 
these,  none  are  more  active  than  mental  and  physical  fatigue 
and  excitement.  Sexual  excesses  and  menstruation  have  a 
similar  effect.  On  the  other  hand,  the  pain  of  ulcer  is  quieted 
by  repose,  and  in  the  uncomplicated  cases  it  subsides  com- 
pletely during  the  night.  The  means,  consequently,  adopted 
to  assure  mental,  physical,  and  moral  repose  are  important 
symptomatic  remedies. 


460  DISEASES  OF  THE  STOMACH. 

The  pain  of  gastric  ulcer  lias  also  an  anatomical  basis. 
The  nerves  are  uncovered  by  the  eroding  process,  and  more 
or  less  neuritis  may  be  present.  The  inflammatory  infiltration 
of  the  walls,  produced  by  irritation  or  by  infection,  or  by  an 
effort  at  repair,  and  the  contraction  of  the  newly-formed  tis- 
sue, compress  the  nerve  filaments.  The  traction  involved  in 
the  production  of  the  deformities  and  the  adhesions  of  parts 
normally  free  are  other  sources  of  irritation  and  pain.  The 
peritoneum  may  become  inflamed  and  exquisitely  sensitive, 
and  perforation  may  occur,  with  its  resulting  purulent  inflam- 
mation, abscess  formation,  and  pus  tunneling.  The  gastric 
mucous  membrane  may  be  hyperesthetic  or  inflamed,  and  its 
secretion  may  be  excessively  acid  and  irritating.  The  pain 
is  also  excited  by  the  chemical,  the  mechanical,  and  the 
thermal  irritants  introduced  into  the  stomach.  The  pain  of 
gastric  ulcer  is  thus  very  complex  in  its  genesis,  and,  neces- 
sarily, very  variable  in  its  intensity  and  in  its  qualities. 

There  is  no  anatomical  disease  of  the  stomach  in  which 
pain  is  so  predominant  as  in  ulcer.  Of  all  the  symptoms  it 
is  the  most  constant,  and  may  be  continuous,  intermittent,  or 
periodical.  It  is  almost  never  absent  after  a  meal  containing 
chemical  irritants  and  large  enough  to  distend  the  stomach. 
During  the  interval  when  the  stomach  is  empty,  and  particu- 
larly at  night,  it  usually  subsides ;  but  in  some  complicated 
cases  (retention,  continuous  secretion,  adhesions,  perigastritis) 
the  patient  is  never  entirely  free  from  pain.  It  may  be  com- 
pletely absent  during  a  period  of  variable  length  without 
evident  reason,  or  after  a  severe  hemorrhage.  As  a  rule,  the 
greater  the  inanition,  the  anemia,  and  the  nervous  exhaustion, 
the  more  constant  and  severe  is  the  pain.  The  pain  may  be 
the  only  symptom,  and,  exceptionally,  it  is  scarcely  noticeable  ; 
but  even  in  the  latent  form  there  has  usually  been  slight,  irreg- 
ular gastric  pain,  considered  by  the  patient  as  insignificant. 
It  is  commonly  severe  enough  to  cause  the  patient  to  seek 
relief. 

The  intensity  and  the  quality  of  the  pain  are  variable,  but 
when  characteristic  it  is  paro.xysmal,  digestive,  severe,  and 
localized.  In  very  old  cases  (probably  with  adhesions  or 
contracting  scars)  the  pain  may  be  dull  and  drawing — a 
peculiar  discomfort  like  that  of  gastroptosis.  In  other  cases 
a  peculiar  sensation,  usually  associated  with  a  little  pain,  is 
felt,  as  if  the  food  were  arrested  and  confined  to  a  particular 
part  of  the  stomach.  The  description  of  the  patient  would 
seem  to  indicate  a  reflex  muscular  effort  to  isolate  or  protect 
the  ulcer.      But  the  characteristic  pain  of  ulcer  is  paroxysmal, 


ULCER    OF  THE   STOMACH.  46 1 

severe,  raw,  gnawing,  burning,  sometimes  pulsating,  often 
excruciating. 

The  spontaneous  pain  begins  in  a  small  area  in  the  epigas- 
trium (Brinton),  or  in  the  back  (Cruveilhier),  and  may  be  as 
strictly  localized  and  circumscribed  as  the  tender  points.  But 
no  negative  conclusions  should  be  drawn  from  the  diffusion 
of  the  pain,  as  that  of  complicated  gastric  ulcer  may  extend 
over  a  large  area.  The  absence  of  a  point  of  greatest  inten- 
sity is  no  evidence  against  the  existence  of  the  ulcer.  The 
epigastric  center  of  spontaneous  pain,  which  maybe  as  small 
as  a  silver  quarter  or  as  large  as  half  of  the  hand,  is  generally 
located  near  the  median  line  and  immediately  below  the  ensi- 
form  process;  but  it  may  be  further  to  the  right,  lower  to  the 
left,  or  higher,  according  to  the  seat  of  the  ulcer  and  to  the 
position  of  the  stomach. 

The  diffusion  of  the  epigastric  pain  is  greatest  when  the 
paroxysms  are  severe  and  when  the  patient  is  of  a  nervous 
temperament.  It  may  be  diffused  over  the  whole  gastric 
region,  over  the  abdomen,  or  over  the  precardiac  region  ;  it 
may  extend  to  the  left  or  to  the  right  or  directly  into  the 
back,  or  through  the  brachial  plexus  into  the  upper  extrem- 
ity. The  excitation  may  be  reflected  along  the  pneumo- 
gastrics,  and  may  produce  dyspnea.  The  extension  of  the 
pain  to  unusual  points  may  be  due  to  complications  involv- 
ing branches  of  the  pneumogastric,  the  intercostal,  and  the 
phrenic  nerves.  When,  for  instance,  the  stomach  is  adherent 
to  the  diaphragm,  and  when  this  muscle  or  its  serous  cover- 
ing is  inflamed,  the  thoracic  points  of  attachment  of  the  dia- 
phragm may  be  tender,  inspiration  may  be  painful,  and  the 
trunk  of  the  phrenic  nerve,  passing  obliquely  across  the 
scalenus  anticus  along  the  posterior  border  of  the  sterno- 
cleidomastoid, is  painful  on  pressure.  In  like  manner  the 
pain  reflected  to  the  right  shoulder  may  be  due  to  adhesions 
to  the  liver. 

The  dorsal  spontaneous  pain  usually  appears  later  than  the 
epigastric.  It  is  also  raw,  burning,  gnawing,  and  at  times 
horribly  severe.  As  a  rule,  it  is  milder  than  the  epigastric 
pain,  but  it  may  exist  alone.  The  most  frequent  localization 
is  to  the  left  (sometimes  to  the  right)  of  the  two  lower  dorsal 
vertebrae  ;  but  it  may  be  lumbar,  even  sacral,  or  may  be  located 
higher  up,  in  the  dorsoscapular  region.  The  location  of  the 
pain  is  supposed  to  be  determined  b\'  the  seat  of  the  ulcer  or 
by  a  complication  of  the  ulcer.  The  dorsal  pain  may  be 
reflected  along  the  intercostal  nerves.  An  extension  to  the 
lower  extremities  is  very  infrequent. 


462  DISEASES  OF  THE  STOMACH. 

The  pain  of  gastric  ulcer  is  alwa\\s  greatest  during  the 
period  of  digestion.  The  distention  and  the  movements  of 
the  stomach,  the  mechanical,  the  chemical,  and  the  thermal 
irritation  by  the  food,  the  superacid  secretion,  and  the  increased 
flow  of  arterial  blood  combine  to  make  the  period  of  functional 
activity  more  painful  than  the  period  of  repose.  The  pain 
may  occur  immediately  after  eating  or  may  be  delayed  half 
an  hour  or  more.  It  increases  with  the  activity  of  digestion 
and  subsides  with  the  evacuation  of  the  stomach,  lasting  about 
two  hours,  unless  cut  short  by  vomiting  or  prolonged  by 
stagnation  or  by  retention. 

A  close  relation  exists  between  the  irritating  qualities  of 
the  food  and  drinks  and  the  degree  of  pain.  It  is  least  after 
a  bland  albuminous  liquid,  like  milk.  Alcoholic,  very  hot  and 
very  cold  drinks,  spices,  acids,  and  coarse,  solid  food  excite  and 
increase  the  pain. 

The  pain  of  ulcer  is  increased  by  the  movements  of  the 
body  and  is  calmed  by  repose.  Even  abdominal  breathing 
may  be  suppressed  in  order  to  keep  the  stomach  still. 

According  to  the  seat  of  the  ulcer,  the  pain  may  be  increased 
or  relieved  by  certain  positions  of  the  body.  The  special  posi- 
tion is  constantly  assumed  by  the  same  patient,  and  is  always 
such  as  protects  the  ulcer  from  pressure  and  from  the  contact 
of  the  gastric  contents  or  prevents  traction  on  painful  adhe- 
sions. 

Vomiting,  though  a  frequent  symptom  of  ulcer,  is  much  less 
characteristic  than  the  pain.  In  some  cases  it  is  the  pre- 
dominant symptom,  and  if  complete  and  persistent  may  lead 
rapidly  to  very  grave  inanition.  In  others  it  occurs  irregularly, 
or  is  incomplete,  or  recurs  periodically.  Seldom  is  it  ab- 
sent throughout  the  course  of  ulcer,  but  it  may  be  replaced 
by  acid  regurgitations  or  by  nausea.  The  frequency  of 
vomiting  is  due  in  part  to  the  constitution  or  temperament, 
some  people  vomiting  more  readily  than  others.  Like  pain, 
it  is  also  favored  by  mental  and  physical  fatigue,  and  by 
nervous  excitement.  But  the  vomiting  which  occurs  in  ulcer 
is  more  frequently  the  result  of  hyperesthesia  of  the  mucous 
membrane  and  of  hypersthenic  gastritis,  and  is  most  fre- 
quent after  solid  and  irritating  food.  In  some  cases  it  is  due 
to  continuous  secretion,  or,  particularly  in  the  old  cases,  to 
pyloric  obstruction  or  to  irritable  adhesions. 

However  caused,  the  vomiting  of  ulcer  (except  in  retention 
or  in  continuous  secretion)  is  digestive.  The  stomach,  if 
hyperesthetic,  may  be  intolerant  of  all  food,  and  the  food  is 
ejected  almost  immediately.      But,  as  a  rule,  it  occurs  from 


ULCER    OF   THE   STOMACH.  463 

half  an  hour  to  two  hours  after  the  meal,  during  the  height  of 
digestion,  when  the  pain  is  intense,  is  produced  easily  without 
nausea,  and  the  pain  is  relieved  if  the  stomach  be  emptied. 
Vomiting  is  usually  followed  by  a  burning  sensation  in  the  car- 
diac region,  lasting  a  few  minutes  ;  but  if  the  stomach  is  not 
completely  emptied,  the  pain  is  only  temporarily  diminished. 
The  vomit  consists  of  an  acid  fluid,  mixed  with  undigested 
remnants  of  food,  and  sometimes  a  little  bile  or  blood.  The 
vomiting  may  occur  after  each  meal,  or  only  after  large  meals 
containing  excitant  food.  In  retention  and  supersecretion 
it  may  take  place  when  the  stomach  normally  should  be 
empty,  and  the  vomit  then  is  characteristic  of  these  two  con- 
ditions. 

Hemorrhage  is  more  frequent  during  the  day  than  at  night, 
but  may  occur  at  any  hour.  Digestion  is  supposed  to  be  the 
most  frequent  exciting  cause,  but  the  blood  is  often  unmixed 
with  food,  showing  that  the  hemorrhage  occurred  when  the 
stomach  was  empty.  The  peristalsis  and  the  distention  inci- 
dental to  the  functional  activity  of  the  stomach,  the  functional 
hyperemia  and  the  increased  blood  pressure,  the  activity  of 
secretion  furnishing  a  strong  digestive  fluid,  the  mechanical 
action  of  the  churned  contents,  may  certainly  be  the  proximate 
causes  of  a  hemorrhage.  Hemorrhage,  however,  often  occurs 
during  the  period  of  gastric  repose,  and  is  occasioned  in  other 
ways.  Among  the  proximate  causes  may  be  mentioned  intense 
excitement,  great  effort,  vomiting,  and  straining  at  stool — all 
increasing  arterial  pressure,  which  bursts  the  thin  wall  of  the 
blood-vessel  or  dislodges  the  clot  from  its  mouth.  Menstru- 
ation is  also  a  proximate  cause,  and  often  the  first  sign  of 
ulcer  is  a  gastric  hemorrhage  occurring  during  the  menstrual 
period.  The  hemorrhage  may  also  be  excited  by  coughing, 
and  it  is  important  to  remember  this  when  differentiating 
gastric  hemorrhage  from  hemoptysis.  The  use  of  the  stomach- 
tube  is  contraindicated  in  ulcer  on  account  of  the  danger  of 
producing  hemorrhage.  The  blood-vessel  maybe  unplugged 
by  the  bacterial  softening  of  the  clot.  The  true  cause  of  the 
hemorrhage  of  ulcer  is  the  opening  of  a  blood-vessel  by 
erosion,  by  necrosis,  and  by  digestion  of  the  devitalized  tissue, 
aided  sometimes  by  increased  blood  pressure  and  by  trauma- 
tism. 

Next  to  pain,  gastric  hemorrhage  is  the  most  frequent 
symptom,  and,  if  small  concealed  hemorrhage  be  counted,  it 
is  probable  that  ulcer  never  runs  its  course  without  this  sign. 
But,  clinically,  the  hemorrhage  is  noted  in  only  about  four- 
fifths  of  the  cases.     The    vomiting   of  blood   (hematemesi.s) 


464  DISEASES  OF  THE  STOMACH. 

occurs  in  30  to  50  per  cent,  of  the  cases,  but  this  percentage 
would  be  increased  if  the  cases  with  small  quantities  of  blood 
in  the  vomit  were  included.  In  the  suspected  cases  the  fre- 
quent detection  of  traces  of  blood  in  the  vomit  (not  ingested 
with  the  meats  nor  due  to  the  retching)  is  a  diagnostic  sign  of 
great  importance.  But  even  a  large  hemorrhage  may  not 
excite  vomiting,  and  with  modern  conveniences  may  escape 
the  notice  of  an  intelligent  patient.  A  loss  of  from  50  c.c.  to 
100  c.c.  of  blood  produces  to  the  layman  no  perceptible  col- 
oration of  the  stool,  and,  on  account  of  the  foul  odor,  if  not 
very  evident  it  is  not  likely  to  be  sought  for  carefully  by  the 
physician.  Hemorrhage  is  observed  in  about  two-thirds  of 
all  cases,  but  it  might  be  detected  if  diligently  sought  for  in 
nearly  every  case.  But  a  single  small  hemorrhage  would  be 
of  very  doubtful  diagnostic  value.  Hemorrhage  maybe  the 
first  sign  of  ulcer,  but  it  commonly  occurs  a  number  of  weeks 
or  months  after  the  pain. 

A  glance  at  the  rich  arterial  supply  of  the  stomach,  and 
the  relations  of  the  large  vessels  to  the  most  common  seats  of 
ulcer,  will  explain  why  this  disease  should  be  so  frequently 
accompanied  by  hemorrhage,  sometimes  small,  frequently 
dangerous,  and  not  infrequently  rapidly  fatal.  The  celiac  axis, 
covered  by  the  lesser  omentum  and  grasped  by  the  lesser  cur- 
vature, furnishes  the  stomach,  directly  and  indirectly,  with  its 
arterial  supply  through  its  three  branches — gastric,  hepatic, 
and  splenic.  These  three  arteries,  through  their  gastric 
branches,  form  on  the  stomach  two  complete  arterial  circuits. 
The  one  is  formed  by  the  coronary  branch  of  the  gastric  and 
the  pyloric  branch  of  the  hepatic  passing  between  the  two 
layers  of  the  lesser  omentum  along  the  lesser  curvature. 
The  other  is  formed  along  the  greater  curvature,  between  the 
folds  of  the  greater  omentum,  b\'  the  union  of  the  left  gastro- 
epiploic, given  off  by  the  splenic,  and  the  right  gastro-epiploic, 
which  is  a  branch  of  the  gastroduodenal  artery,  given  off 
by  the  hepatic.  The  stomach  also  receives  at  its  pyloric 
end  small  branches  from  the  gastroduodenal  artery.  The 
splenic,  the  largest  branch  of  the  celiac  axis,  after  meander- 
ing along  the  upper  border  of  the  pancreas  and  giving  off 
the  left  gastro-epiploic,  distributes  between  tiie  two  layers  of 
the  gastrosplenic  omentum  several  branches  to  the  greater 
curvature  of  the  stomach,  which  anastomose  with  the 
branches  of  the  left  gastro-epiploic  and  of  the  gastric  arteries. 

The  branches  of  these  arterial  circuits,  and  the  smaller 
anastomosing  branches,  form  over  the  surface  of  the  stomach 
a  network  of  small  arteries,  which  send  branches  to  the  mus- 


ULCER    OF  THE   STOMACH.  465 

cular  coat,  and  ramify  in  the  submucous  coat,  to  be  finally 
distributed  to  the  mucous  membrane  in  the  form  of  a  net- 
work of  capillaries  covering  the  gastric  tubules  and  passing 
up  between  them  to  encircle  the  mouths  of  the  ducts.  From 
this  superficial  encircling  network  the  blood  is  taken  up  by 
the  venous  radicles,  and  is  returned  through  the  splenic,  the 
superior  mesenteric,  and  the  portal  veins.  The  pyloric,  the 
splenic,  and  the  coronary  branches  of  the  gastric  are  the  large 
arteries  most  frequently  opened.  Sometimes  it  is  the  right 
epiploic  ;  the  branches  of  the  splenic  artery,  being  distributed 
to  a  region  of  the  stomach  seldom  affected  by  ulcer,  generally 
escape.  The  liability  to  a  profuse  hemorrhage  increases  with 
the  depth  of  the  ulcer. 

Clinically,  gastric  hemorrhage  may  be  rapidly  fatal;  imme- 
diately dangerous  ;  profuse  and  recurrent ;  and  small,  con- 
cealed, and  dangerous  on  account  of  the  repetitions. 

Rapidly  fatal  hemorrhage  occurs  in  about  three  per  cent, 
of  the  cases  of  ulcer,  and  is  due  to  the  opening  of  a  large 
artery,  usually  one  of  the  branches  of  the  celiac  axis.  Some- 
times an  aneurysm  has  previously  formed  at  the  weak  point  of 
the  eroded  wall.  Suddenly,  without  warning,  the  patient  be- 
comes pale,  weak,  anxious ;  faints,  falls  unconscious,  and  dies 
after  vomiting  blood,  which  is  very  little  changed  unless  the 
accident  happens  during  digestion. 

Death  may  occur  before  vomiting  takes  place.  The  hem- 
orrhage may  be  profuse  and  concealed,  but  not  so  rapidly  fatal, 
the  stomach  consuming  fifteen  or  twenty  minutes  in  filling, 
the  vomiting  being  rapid  and  effortless,  and  followed  by  col- 
lapse, rolling  from  side  to  side,  delirium,  stupor,  and  death 
after  a  short  interval  of  two  or  three  days.  The  vomited 
blood  is  clotted,  pure,  unless  accidentally  mixed  with  the 
contents,  and  may  be  ejected  with  such  force  and  in  such 
quantity  as  to  fill  the  mouth,  the  nose,  and  the  throat.  Some- 
times, but  not  often,  vomiting  does  not  occur,  and  the  blood 
is  evacuated  within  twenty-four  hours  by  the  bowels,  unless 
death  occurs  earlier. 

A  large  and  immediately  dangerous  hemorrhage  is  more 
common  and  characteristic  of  ulcer.  The  more  profuse  a 
gastric  hemorrhage,  the  more  likely  is  it  to  be  due  to  ulcer. 
Three  or  four  ounces  of  blood  at  a  time  are  frequently  lost  in 
cancer  of  the  stomach,  and  small  gastric  hemorrhages  occur 
in  a  number  of  diseases  ;  but  a  gastric  hemorrhage  of  from 
one  to  three  pints  is  nearly  always  due  to  ulcer.  The  dan- 
gerous form  is  ushered  in  by  the  usual  signs  of  severe  hemor- 
rhage— pallor,  weak  pulse  and  heart,  vertigo,  great  thirst,  syn- 
30 


466  DISEASES  OF  THE  STOMACH. 

cope.  The  stomach  is  full  and  feels  warm  ;  the  blood  rises 
into  the  mouth,  and  large  quantities  are  vomited  without 
effort  or  pain.  The  blood  is  dark  and  clotted,  the  appear- 
ance varying  according  to  the  time  that  it  has  remained  in 
the  stomach  and  to  the  quantity  of  HCl  with  which  it  has 
come  in  contact.  Immediately  after  the  cessation  of  the  hem- 
orrhage the  patient  is  weak,  exhausted,  the  extremities  are 
moist  and  cold  ;  he  complains  of  vertigo  and  of  ringing  in  the 
ears  ;  the  temperature  of  the  body  rises  because  so  little  blood 
goes  to  the  surface,  but  the  fever  soon  subsides;  there  may 
be  dark  spots  in  the  field  of  vision,  even  amaurosis  ;  palpita- 
tion is  frequent ;  dyspnea  after  the  least  effort;  he  is  anxious, 
and  has  restless  nights  and  broken  sleep.  The  subsequent 
course  is  that  of  hemorrhagic  anemia,  which  may  disappear 
in  one  or  two  months. 

The  hemorrhage  may  be  profuse  and  may  recur  fre- 
quently, death  taking  place  in  four  or  five  days  ;  or  the  hem- 
orrhage may  cease  after  occurring  intermittently  a  number  of 
days  or  weeks,  and  the  patient  may  eventually  get  well.  The 
repeated  hemorrhages  may  be  due  to  the  progress  of  the 
morbid  process,  to  deficient  coagulability  of  the  blood,  or  to 
the  fact  that  the  blood-vessel  is  opened  and  not  divided  so  as 
allow  its  coats  to  retract.  The  blood  vomited  represents  only 
a  part  of  that  lost,  the  remainder  passing  into  the  intestines. 

Equally  pernicious  are  the  small  repeated  hemorrhages, 
usually  escaping  detection.  The  anemia  is  severe,  and  the 
emaciation  and  the  cachexia  are  remarkable,  the  termination 
often  being  death.  These  little  hemorrhages  may  occur  early 
when  the  ulcer  is  eating  its  way  through  the  mucous  mem- 
brane, but  sometimes  later  in  the  anatomical  progress  of  the 
ulcer,  and  they  may  be  venous.  There  is  neither  hemate- 
mesis  nor  perceptible  melena.  Traces  of  blood  must  be  sought 
for  in  the  gastric  contents  and  in  the  stools.  Infrequently 
the  hemorrhage  is  slow,  and  eventually  vomiting  may  be  ex- 
cited by  the  accumulated  blood  ;  the  vomit,  then,  is  brownish- 
black,  like  coffee  grounds,  consisting  of  blood  pigment,  debris 
of  cells,  fluid,  often  food,  and  sometimes  sarcinre.  This  form 
of  hematemesis  is  most  common  in  the  cachectic  stage  of  ulcer 
and  in  the  retention  stage  of  pyloric  obstruction. 

Melena  may  be  the  only  symptom  of  ulcer.  The  blood  is 
small  in  quantity,  and  is  homogeneously  mixed  with  the  con- 
tents of  the  bowel,  forming  a  soft,  chocolate-colored  mass. 
If  a  large  quantity  of  blood  passes  into  the  duodenum,  the 
stool  is  tarry,  is  often  blown  to  pieces  with  gas,  and  is  exceed- 
ingly foul.    After  nearly  every  gastric  hemorrhage  blood  may 


ULCER    OF   THE   STOMACH.  467 

be   detected   in    the    stool,   and   melena   may  occur  without 
hematemesis. 

In  a  case  of  hematemesis  or  of  melena  two  questions  must 
be  answered  :  Is  the  hemorrhage  gastric  ?  and  is  it  due  to  an 
ulcer?  But  before  searching  for  the  location  or  the  cause  of 
the  hemorrhage  it  is  first  necessary  to  detect  its  existence. 
This  is  not  so  easy  as  might  be  supposed,  and  a  small  hemor- 
rhage may  escape  the  close  observation  of  both  patient  and 
physician,  as  hematemesis  and  visible  melena  may  not  occur. 
In  suspected  cases  it  is  always  essential  to  examine  both  the 
vomit  and  the  stools  by  the  methods  already  described  for 
detecting  therein  traces  or  small  quantities  of  blood,  and  also 
to  examine  the  blood  itself  for  characteristic  signs  of  hemor- 
rhagic anemia. 

Having  detected  blood  either  in  the  vomit  or  in  the  stools, 
or  a  hemorrhagic  anemia,  search  should  next  be  made  for 
its  origin.  It  should  not  be  forgotten  that  traces  of  blood 
may  be  introduced  with  the  food.  Blood  found  in  the  vomit 
may  have  originated  in  the  stomach,  in  the  esophagus,  the 
pharynx,  the  nose,  the  mouth,  the  respiratory  tract,  or  even 
the  duodenum.  The  origin  in  the  mouth,  the  nose,  the  throat, 
and  the  larynx  can  be  detected  or  excluded  by  careful  inspec- 
tion ;  and  this  examination  should  never  be  omitted. 

The  differentiation  of  pulmonary  and  of  gastric  hemor- 
rhage may  be  difficult,  but  can  usually  be  readily  made  with 
certainty.  The  evidence  of  the  patient  is  frequently  worth- 
less. Some  blood  may  get  into  the  larynx  during  the  act  of 
vomiting  and  may  be  coughed  up.  The  blood  coming  from 
the  lungs  in  slight  hemorrhage  may  be  all  swallowed,  and, 
being  afterward  vomited,  may  present  difficulties  that  are  not 
easy  to  overcome,  especially  when  the  signs  of  pulmonary 
tuberculosis  and  painful  digestion  or  ulcer  coexist.  This  is 
more  likely  to  happen  with  women.  To  make  the  differentia- 
tion, it  is  best  to  proceed  in  a  methodical  manner.  Do  the 
clinical  history  and  the  objective  examination  reveal  a  disease 
of  the  lungs,  or  of  the  heart,  or  of  the  esophagus,  of  the 
liver,  or  of  the  stomach  ?  If  a  disease  be  detected,  the  evolu- 
tion of  which  is  accompanied  by  gastric  or  pulmonary  hemor- 
rhage, the  discovery  is  strong  presumptive  evidence  of  the 
source  of  the  blood. 

The  method  of  beginning,  when  carefully  observed,  is  of 
great  importance.  Hemoptysis  begins  with  tickling  in  the 
throat,  with  cough,  and  with  the  expectoration  of  red  blood. 
Hematemesis  begins  with  the  symptoms  of  internal  hemor- 
rhage, and   with  a   feeling  of  distention  and  of  heat  in   the 


468  DISEASES  OF  THE  STOMACH. 

Stomach.  The  warm  blood  mounts  along  the  esophagus  to 
the  throat,  and  nausea  is  followed  by  vomiting. 

The  signs  following  the  hemorrhage  may  be  conclusive. 
In  hemopt\'sis  the  sputum  brought  up  by  coughing  con- 
tinues for  several  days  to  be  bloody,  and  for  a  short  period 
thereafter  the  blood  expectorated  is  red,  and  does  not  consist 
of  particles  that  have  accidentally  gotten  into  the  larynx.  In 
hematemesis  the  sputum  becomes  quickly  clear  if  the  mouth 
and  the  throat  have  been  freed  from  blood. 

In  hemoptysis  there  is  frequently  fever  ;  in  gastric  hemor- 
rhage fever  is  ephemeral  and  due  to  the  loss  of  blood,  and  the 
stools  frequently  contain  blood  at  some  time  during  the  fol- 
lowing forty-eight  hours.  Ulcer  is  an  afebrile  disease  unless 
it  be  complicated. 

In  hemoptysis  the  blood  is  red  in  the  beginning,  and  is 
mixed  with  air.  Later  the  sputum  may  contain  both  dark 
and  red  blood.  In  hematemesis  the  blood  is  nearly  always 
dark,  and  presents  the  changes  peculiar  to  the  action  of  HCl. 

The  differentiation  of  esophageal  and  of  gastric  hemor- 
rhage may  be  very  difficult.  The  search  for  the  causative 
disease  should  first  receive  attention — cancer,  ulcer,  varicose, 
veins,  or  the  rupture  of  an  aneurysm.  The  use  of  neither  the 
esophageal  nor  the  gastric  sound  is  permissible.  The  dis- 
covery of  a  disease  productive  of  passive  congestion  in  the 
portal  system  is  of  differential  value.  The  blood  from  the 
esophagus  is  dark,  but  not  chocolate-  or  coffee-colored,  and  is 
expelled  without  the  effort  of  vomiting.  The  blood  goes  also 
into  the  stomach  and  hematemesis  or  melena,  one  or  the  other, 
or  both,  may  occur.  The  clinfcal  history  is  of  most  value. 
There  is,  in  the  one  case,  a  history  of  esophageal  pain,  located 
behind  the  sternum  and  extending  into  the  back  and  shoulders, 
or  of  stricture.  Both  s\'mptoms  are  manifest  during  swallow- 
ing. In  the  other  case  the  symptoms  are  located  in  the  stomach, 
and  begin  after  the  food  has  reached  this  organ.  In  all  cases 
of  esophageal  ulcer  there  is  vomiting. 

Blood  found  in  the  stools  may  have  entered  at  any  point 
of  the  alimentary  canal,  and  it  may  be  impossible  to  locate 
the  source  of  the  hemorrhage;  but  the  presumption  is  in 
favor  of  its  gastric  origin  when  there  is  no  discoverable  in- 
testinal disease  and  where  there  is  a  history  of  gastric  trouble. 
The  blood,  when  in  too  small  quantity  to  excite  diarrhea,  is 
intimately  mixed  with  the  fecal  matter,  and  so  altered  as  to 
be  often  recognizable  only  by  the  chemical  tests. 

Objective  Signs. — The  chief  positive  physical  signs  of 
simple  ulcer  of  the  stomach,  of  diagnostic  value,  are  the  epi- 


ULCER    OF   THE   STOMACH.  469 

gastric  and  the  dorsal  tender  points.  These  points  are  char- 
acterized by  their  locaHzation,  sharp  Hmitation,  and  very  great 
sensitiveness. 

The  epigastric  point  is  located  on  or  very  near  the  median 
line,  close  to  the  ensiform  process.  The  location  may  vary 
according  to  the  seat  of  the  ulcer  and  to  the  position  of  the 
stomach.  Consequently,  it  may  sometimes  be  a  little  to  the 
right  or  to  the  left,  or  lower  down.  It  is  commonly  of  an  area 
of  about  the  size  of  a  silver  dollar,  and  the  location  in  a  given 
case  is  constant. 

This  small,  tender  area  is  sharply  limited,  and  does  not  cor- 
respond in  form  and  location  with  the  left  lobe  of  the  liver. 
In  some  cases  the  whole  epigastric  region  is  sensitive,  par- 
ticularly if  the  examination  be  made  when  the  stomach  is  not 
empty.  The  production  of  the  pain,  when  the  stomach  con- 
tains fluid,  by  the  little  successive  shocks  employed  to  elicit 
the  splashing  sounds  is  a  distinctive  feature.  The  epigas- 
trium may  also  be  hyperesthetic,  but  with  care  the  small  and 
more  sensitive  area  can  be  detected  and  its  boundaries  can 
be  defined. 

The  epigastric  point  is  very  sensitive,  more  so  than  in  any 
other  disease  of  the  stomach,  where  from  two  to  four  times 
the  amount  of  pressure  is  needed  to  produce  true  pain.  But 
in  a  number  of  cases  the  sensitiveness  is  not  so  great  as  to  be 
characteristic,  and  the  sign  alone  should  not  be  given  too  great 
importance.  The  degree  of  sensitiveness  varies  in  different 
cases  and  in  the  same  case  at  different  times.  The  epigastric 
spot  is  characteristic  in  about  two-thirds  of  the  cases,  and 
may  be  present  when  all  subjective  signs  are  absent. 

The  dorsal  point  is  about  the  size  of  a  silver  dollar  and  is 
located  about  an  inch  to  the  left  of  the  two  last  dorsal  verte- 
brae. It  is  sharply  limited,  but  not  so  sensitive  as  the  epigas- 
tric point.  Sometimes  a  second  sensitive  area  coexists,  to  the 
right  of  the  spine  on  the  same  level,  but  requires  greater 
pressure  to  elicit  true  pain.  Sometimes  the  point  on  the  right 
is  the  more  tender,  and  it  may  exist  alone.  Two  similar  points 
may  be  located  on  a  level  with  the  fourth  and  the  fifth  dorsal 
vertebrae;  but  this  is  not  characteristic  of  ulcer,  but  is  due  to 
reflex  excitation  of  the  spinal  sensory  nerves  by  the  irritable 
sympathetic  ganglia.  The  lower  dorsal  point  exists  in  about 
one-third  of  the  cases  of  ulcer,  and  its  diagnostic  value  is 
variously  estimated. 

In  the  same  case  the  degree  of  sensitiveness  of  the  dorsal 
point  is  more  variable  and  the  point  itself  less  persistent  than 
the  epigastric  tender  point.     Taken  in  combination  with  other 


470  DISEASES  OF  THE  STOMACH. 

ulcer  symptoms,  tlie  dorsal  point  is  a  confirmatory  sign  of 
value. 

A  physical  sign  of  ulcer,  much  more  common  than  is  gen- 
erally admitted,  is  a  palpable  tumor.  If  the  ulcer  be  recent, 
it  consists  only  of  a  defect  of  the  mucous  membrane,  but  pos- 
sibly it  also  extends  deeper  ;  in  either  case  no  tumor  will  be 
felt.  In  old  ulcer,  however,  the  edges  may  be  thickened  and 
infiltrated,  and  if  then  it  be  located  in  the  part  of  the  anterior 
wall  accessible  to  palpation,  or  in  another  region  made  acces- 
sible to  the  fingers  by  displacement  of  the  stomach,  a  flat,  thin, 
and  tender  tumor  can  be  felt.  The  pylorus  may  be  thick- 
ened, or  hard  and  contracted,  if  the  ulcer  is  located  near  it. 
These  forms  of  tumors  are  not  complicated  by  adhesions,  and 
can  be  easily  fi.xed  on  expiration.  More  common  and  char- 
acteristic are  the  tumors  formed  by  inflamed  adherent  organs 
and  by  inflammatory  exudation.  The  localized  inflammation 
and  infiltration  of  the  adherent  organ  produces  a  circumscribed 
mass,  which  is  hard  and  is  easily  defined  by  the  e.xamining  fin- 
gers. The  head  of  the  pancreas,  when  felt,  is  deep,  immov- 
able, hard, and  enlarged;  or  the  mass  may  be  in  the  adherent 
left  lobe  of  the  liver,  and  may  ascend  and  descend  with  respira- 
tion in  close  union  with  the  diaphragm.  The  ulcer  tumor 
may  long  remain  stationary,  or  is,  at  least,  not  slowly  and 
regularly  progressive.  It  is  tender,  develops  as  a  consequence 
of  inflammation,  and,  considered  in  connection  with  the  clinical 
history  and  the  syinptoms  and  other  signs,  may  be  very 
important  in  the  diagnosis  of  ulcer.  The  age,  the  stationary 
character,  the  tenderness,  and  the  absence  of  secondary 
nodules  may  be  valuable  in  excluding  a  suspected  cancer. 

In  ulcer  of  the  stomach  the  state  of  nutrition  is  variable. 
In  the  mild  clinical  forms,  where  enough  food  is  taken  and 
retained,  and  the  loss  of  blood  is  insignificant,  the  strength  and 
the  weight  may  be  maintained,  and  the  general  appearance 
may  be  that  of  excellent  health.  But  such  a  state  of  nutri- 
tion is  exceptional,  and  pain,  vomiting,  hemorrhage,  and  the 
insufficient  and  exclusively  liquid  diet  spontaneously  adopted 
after  a  certain  length  of  time  produce  emaciation  and  inani- 
tion. Indeed,  in  complicated  cases,  or  where  little  food  has 
been  utilized  for  a  long  time,  the  inanition  may  be  fatal. 
About  five  per  cent,  of  the  deaths  from  ulcer  are  due  to 
starvation.  An  insignificant  hemorrhage  in  this  state 
of  extreme  emaciation  may  prove  to  be  a  death-stroke. 
These  cachectic  cases  are  more  frequent  after  the  fortieth 
year.  Inanition  is  more  frequent,  and  emaciation  ma\'  be  more 
pronounced  in  ulcer  than  in  any  other   non-malignant  disease 


ULCER    OF   THE   STOMACH.  47 1 

of  the  stomach,  and  the  cachexia  may  be  as  marked  as  in  ad- 
vanced carcinoma. 

In  round  ulcer  of  the  stomach  the  blood  may  be  normal 
or  it  may  be  diseased ;  the  disease  of  the  blood  may  be  pri- 
mary, or  it  may  be  secondary,  and  due  to  inanition  and  to 
hemorrhage.  The  relations  of  anemia  and  chlorosis  to  the 
genesis  of  ulcer  have  already  been  discussed.  The  sympto- 
matic blood  trouble  is  always  oligocythemia. 

A  single  small  hemorrhage  may  produce  a  very  slight  and 
temporary  disturbance;  a  single  large  hemorrhage  is  fol- 
lowed by  greater  changes,  and  the  phenomena  of  regenera- 
tion of  the  blood  are  more  marked;  repeated  hemorrhages, 
though  small,  lead  in  the  course  of  time  to  very  grave 
oligocythemia.  This  is  very  clearly  seen  in  the  hemorrhagic 
form  of  ulcer,  and  where  there  are  frequent  small  and  con- 
cealed hemorrhages  without  either  hematemesis  or  visible 
melena.  The  great  recuperative  power  of  the  blood  is  a  dis- 
tinctive characteristic  of  the  blood  in  ulcer  of  the  stomach. 

After  a  single  small  hemorrhage  the  number  of  red  cells 
and  the  percentage  of  hemoglobin  are  proportionately  dimin- 
ished, and  there  is  in  a  few  hours  a  slight  increase  in  the 
number  of  the  polynuclear  white  cells,  and  a  few  nucleated 
red  cells  may  appear  after  a  few  days.  The  red  corpuscles 
are  all  of  the  normal  size.  A  comparison  of  the  results  of  the 
examination  of  the  blood  a  short  time  before  and  after  the 
hemorrhage  in  a  case  of  ulcer  would  reveal  the  occurrence  of 
the  hemorrhage. 

After  a  single  large  hemorrhage,  which  is  almost  sure  to  be 
accompanied  by  hematemesis,  the  hemoglobin  and  the  num- 
ber of  red  cells  are  diminished,  the  percentage  of  hemoglobin 
divided  by  the  percentage  of  red  cells  is  equal  to  unity,  and  the 
number  of  lymphocytes  and  polynuclear  white  cells  is  notably 
and  absolutely  increased.  After  a  few  hours  the  blood 
formula  begins  to  change,  and  in  a  few  days  becomes  char- 
acteristic. The  blood  is  flooded  with  small  nucleated  red 
corpuscles  ;  the  common  red  corpuscles  and  the  hemoglobin 
increase,  but  the  cell  regeneration  is  faster  than  that  of  the 
hemoglobin,  so  that  the  above  fraction  is  less  than  unity.  The 
number  of  red  corpuscles  are  gradually  recovered,  and  the 
white  corpuscles  soon  drop  down  to  their  normal  proportion 
and  number.  The  regeneration  is  greatly  prolonged  if  re- 
peated small  concealed  hemorrhages  occur.  A  sudden  arrest 
or  a  fall  in  the  regeneration  or  in  the  richness  of  the  blood, 
respectively,  would  be  a  sign  of  hemorrhage.  The  blood 
changes  are  thus  revealing  signs. 


4/2  DISEASES  OF  THE  STOMACH. 

Repeated  small  hemorrhages  are  very  frequent  in  ulcer. 
They  may  or  may  not  be  associated  with  a  severe  hemor- 
rhage. These  small  and,  in  themselves,  insignificant  hem- 
orrhages cause  neither  vomiting  nor  coloration  of  the  stools 
sufficient  to  attract  the  eye.  Their  repetition  renders  them 
serious,  and  a  knowledge  of  their  existence  would  confirm  a 
provisional  diagnosis  of  ulcer.  The  blood  will  be  found  to 
have  a  diminished  number  of  red  corpuscles,  a  diminution  of 
the  hemoglobin,  and  the  percentage  fraction  is  less  than  unity  ; 
the  number  of  small  nucleated  red  corpuscles  is  increased,  and 
also  the  number  of  white  corpuscles.  There  are  sudden 
changes  for  the  worse,  and  the  recurring  little  blood  crises 
indicate  the  small  concealed  hemorrhages.  In  all  cases  of 
gastric  ulcer  the  blood  should  be  carefully  watched.  In 
hemorrhagic  oligocythemia  there  are  no  signs  of  degenera- 
tion of  the  corpuscles,  no  s.igns  of  dyshematopoiesis,  and  no 
signs  of  hematocytolysis  occurring  in  the  circulating  blood. 
The  oligocythemia  is  due  to  the  loss  of  blood  by  hemor- 
rhage. 

The  anemia  of  gastric  ulcer  may  be  due  to  inanition.  Pain 
in  itself  may  exert  an  influence,  vomiting  may  rob  the  organ- 
ism of  some  of  its  nutriment,  but  the  chief  cause  of  the 
inanition  is  voluntary  starvation.  The  person  feels  best  when 
he  eats  little  and  gives  the  irritable,  sensitive  organ  rest. 

The  blood  formula  of  inanition  anemia  is  different  from 
that  due  to  hemorrhage.  A  distinction  should  be  made  be- 
tween the  effects  of  abstinence  due  to  gastric  intolerance 
and  a  starvation  diet.  In  complete  abstinence  and  in  fasting 
with  the  exclusion  of  all  but  water,  in  spite  of  the  starved 
appearance,  in  the  cubic  millimeter  of  blood  there  is  the 
normal  proportion  and  quantity  of  red  corpuscles  and 
of  hemoglobin ;  but  the  number  of  white  corpuscles  is 
rapidly  and  markedly  diminished.  This  fall  may  go  even 
below  looo  to  the  cubic  millimeter.  It  is  well  known  that 
digestion  destroys  and  draws  from  the  general  circulation 
to  the  digestive  tube  a  large  number  of  the  white  cells  ;  but 
the  effect  of  this  momentary  diminution  of  the  number  of 
the  circulating  corpuscles  is  the  generation  and  the  entrance 
into  the  circulation  of  an  excess  of  white  corpuscles.  This 
is  known  as  digestive  leukocytosis.  It  seems  to  be  a  general 
rule  that  leukocytolysis  is  followed  by  leukocytosis,  and  this, 
whether  it  be  the  result  of  using  the  white  cells  as  phago- 
cytes, as  in  the  infectious  diseases,  or  in  absorption  and  as- 
similation. In  starvation,  this  digestive  and  assimilative  use 
of  the  white  cells  is  suppressed.     The  absence  of  the  demand 


ULCER    OF   THE   STOMACH.  473 

leads  to  decreased  production,  and  eventually  to  diminished 
productive  power. 

In  chronic  inanition,  the  conditions  are  different.  The 
individual  is  trying  to  live  on  insufficient  food.  The  blood 
may  long  maintain  itself  at  the  expense  of  the  fat  and  the 
muscles,  and  the  percentage  of  formed  constituents  in  the 
cubic  millimeter  of  blood  may  even  increase.  The  patient 
looks  starved,  and  the  corpuscular  richness  of  the  blood  is 
a  surprise.  At  a  later  stage  the  hemoglobin  and  the  cor- 
puscles all  decrease,  and  maybe  reduced,  in  starvation  cache- 
xia, to  one-fifth  of  the  normal  number.  An  emaciated,  weak 
patient  with  a  normal  blood  formula  is  suffering  from  inani- 
tion. The  blood  in  severe  inanition-oligocythemia  displays 
signs  of  degeneration,  of  dyshematopoiesis,  and  of  hematocy- 
tolysis. 

The  anemia  is  not  always  pure,  but  may  be  due  to  the  com- 
bined influence  of  inanition  and  of  hemorrhage,  and  in  the 
complicated  cases  with  pus  formation  or  with  retention  and 
fermentation,  is  partly  also  the  result  of  auto-intoxication. 
These  mixed  forms  of  anemia  may  become  exceedingly  grave. 
The  blood  displays  the  signs  of  dyshematopoiesis,  of  hemato- 
cytolysis,  and  of  degeneration,  in  combination  and  in  divers 
degrees. 

The  functional  signs  of  ulcer  are  in  no  wise  characteristic, 
but  may  possess  a  certain  diagnostic  value.  In  every  case 
where  there  is  good  reason  for  suspecting  the  existence  of 
an  ulcer,  the  use  of  the  stomach-tube  is  contraindicated. 
While  it  is  true  that  the  tube  may  be  employed  without 
accident,  the  procedure  is  dangerous,  and  may  excite  hemor- 
rhage. If  the  tube  be  used  in  a  suspicious  case,  the  throat 
should  be  sprayed  with  cocain,  the  contents  aspirated,  the 
stomach  left  empty,  and  the  tube  withdrawn  if  the  patient 
should  make  an  effort  to  vomit.  The  functional  exploration 
is  reduced,  as  a  rule,  by  the  contraindication  to  the  use  of  the 
tube,  to  an  examination  of  the  vomit,  which,  in  the  majority 
of  cases  (70  per  cent.),  will  be  found  more  acid  than  it  should 
be  at  the  moment  in  the  evolution  of  digestion  when  the 
vomiting  occurred.  In  other  cases  the  acidity  is  normal  or, 
rarely,  less  than  normal.  In  nineteen  cases,  studied  by  the 
careful  use  of  the  tube,  we  found  pyloric  obstruction  already 
present  in  three  cases,  which  will  be  left  out  of  considera- 
tion on  this  account.  In  1 1  of  the  remaining  cases  there 
was  hydrochloric  superacidity,  and  three  of  these  showed  a 
moderate  prolongation  of  digestion  due  to  supersecretion.  In 
four  cases  secretion  was  normal  in  quantity  and  in  evolution. 


474  DISEASES  OF  77/ E  STOMACH. 

and  in  one  there  was  hypochylia — the  time  for  the  exam- 
inations being  selected  so  as  to  eliminate  the  influence  of 
subnutrition  and  hemorrhage.  In  tliree  of  tiie  cases  with 
hydrochloric  superacidity  secretion  became  normal  during  the 
second  week  of  the  ulcer  treatment.  Hayem  reports  secre- 
tion normal  in  three  of  a  total  of  22  cases  with  no  obstruction 
of  the  pylorus.  The  vomit  may  also  show  signs  characteris- 
tic of  other  diseases,  or  such  as  are  found  in  the  complica- 
tions of  ulcer.  In  uncomplicated  ulcer  the  motor  function 
is  efficient,  there  is  no  decrease  of  absorption,  there  are 
no  abnormal  bacteriological  signs,  and  no  variation  in 
digestive  activity,  except  that  resulting  from  the  frequent 
hydrochloric  superacidity.  The  functional  signs  may  be  of 
some  value  in  confirming  the  existence  of  ulcer,  or  in  exclud- 
ing it,  by  revealing  a  complication  or  another  disease.  This 
information  may  be  obtained  from  repeated  examinations  of 
the  vomit  or  by  the  careful  use  of  the  stomach-tube. 

Constipation  is  the  rule  in  ulcer,  and  the  bowels  usually 
require  aid  in  order  to  prevent  fecal  accumulation.  A  few 
diarrheal  movements  are  sometimes  excited  by  decomposing 
blood. 

Terminations. — Ulcer  may  terminate  in  cure,  in  death,  or 
in  chronic  invalidism.  The  oligocythemia  and  the  inanition 
resulting  from  ulcer  are  favorable  to  the  development  of  infec- 
tious diseases,  which  may  prove  fatal. 

The  healing  of  the  ulcer  is  characterized  by  the  subsidence 
of  the  symptoms  and  objective  signs.  Of  the  cardinal  symp- 
toms, the  hemorrhage  is  the  first  to  disappear.  Hemor- 
rhage proves  that  the  morbid  process  is  progressing,  though 
when  it  occurs,  some  parts  of  the  ulcer  may  be  cicatrizing. 
Vomiting  ceases  or  is  accidental  and  occasional.  The  pain 
diminishes,  becomes  purely  digestive,  and  exists  only  after 
solid  or  irritant  food  or  after  physical  or  mental  fatigue. 
The  tender  dorsal  and  epigastric  points  become  less  and 
less  sensitive  and  finally  disappear.  With  the  healing  of 
the  ulcer  disappears  also,  as  a  rule,  the  digestive  hyperchlor- 
hydria.  The  ulcer  before  completely  healing  presents  a 
purely  anatomical  period  without  signs  or  symptoms.  About 
one-half  of  the  cases  of  ulcer  recover  without  leaving  an 
impairment  of  the  digestive  functions  as  a  permanent  legacy. 

The  mortality  from  ulcer  is  usually  placed  too  high.  Some 
authors  state  that  50  per  cent,  of  the  cases  terminate  fatally  ; 
but  the  statistics  are  compiled  from  cases  reported  in  medical 
literature.  If  death  from  intercurrent  diseases  (tuberculosis, 
cancer)  be  excluded,  the  mortality  of  the  clinical  (non-latent) 


ULCER    OF   THE   STOMACH.  475 

forms  is  about  one  in  seven,  and  this  percentage  may  be 
reduced  by  treatment.  Death  may  be  due  to  perforation 
(causes  death  in  80  per  cent,  of  deaths  due  to  ulcer),  to  severe 
hemorrhage  (two  per  cent.),  or  to  other  compHcations  (five  per 
cent.),  such  as  inanition,  hemorrhagic  anemia,  and  deformities. 

The  remainder  of  the  cases  become  chronic  invalids.  The 
functions  of  the  stomach  may  be  compromised  by  adhesions 
or  by  deformities.  The  scars  may  be  neuralgic.  The  sequelae 
may  give  persistent  trouble  without  being  incompatible  with 
life.  Death  from  the  effects  of  the  ulcer  is  frequently  pre- 
vented only  by  the  intervention  of  a  fatal  intercurrent  disease. 

Diagnosis. — The  diagnosis  of  ulcer  may  be  sure,  doubtful, 
or,  in  a  third  class  of  cases,  there  may  be  only  cause  to  sus- 
pect the  existence  of  this  severe  disease.  Naturally,  the 
anatomical  (latent)  form  goes  unrecognized,  and,  also,  during 
an  anatomical  period  ulcer  would  be  either  unsuspected  or 
would  be  considered  cured.  The  clinical  forms  are  often 
atypical  in  their  expression.  Whoever  waits  for  all  the  car- 
dinal symptoms — pain,  vomiting,  and  hemorrhage — to  be 
present,  with  their  distinctive  features,  before  making  the 
diagnosis  of  ulcer,  will  discover  it  late,  and  will  overlook 
entirely  a  majority  of  the  cases. 

The  clinical  expression  of  ulcer  being  so  variable,  it  is 
difficult  to  enumerate  all  the  cases  which  fall  under  the  three 
divisions — sure,  doubtful,  and  suspicious.  "  I  am  inclined  to 
think,"  wrote  Brinton,  "that  nothing  less  than  a  concurrence 
of  the  chief  symptoms  entitles  us  to  pronounce  a  decided 
opinion.  In  other  words,  unless  the  pain  possess  the  charac- 
teristics attributed  to  it,  and  is  accompanied  by  an  equally 
characteristic  vomiting,  and  unless  there  be  evidence  of  con- 
siderable or  repeated  hemorrhage  in  the  course  of  the  malady, 
there  is  no  sufficient  ground  for  affirming  the  existence  of 
gastric  ulcer."     These  requirements  are  too  exacting. 

Wherever  the  three  cardinal  symptoms  are  present  there 
can  be  no  doubt.  If  the  spontaneous  pain  and  the  tender 
points  are  present,  with  the  definite  characteristics  already 
minutely  described,  there  should  be  little  need  of  confirmation 
by  the  other  signs,  such  as  vomiting,  hyperchlorhydria,  hem- 
orrhage, and  the  state  of  the  blood  and  of  nutrition.  A  large 
gastric  hemorrhage,  in  the  absence  of  the  symptoms  of  other 
diseases  which  might  cause  it,  may  also  be  considered  con- 
clusive. There  need  be  no  hesitation  if,  associated  with  the 
gastric  hemorrhage,  are  the  special  pain,  the  painful  digestion, 
the  vomiting,  and  the  objective  signs  ;  not  all  these  combined 
need  be  present,  but  one  or  more,  with  their  typical  charac- 


476  DISEASES  OF  THE  STOMACH. 

teristics.  A  positive  diagnosis  can  be  made  in  niucli  less 
than  a  majority  of  the  cases  of  ulcer. 

But  none  of  the  cardinal  symptoms  may  be  present  in  their 
typical  forms,  and  the  symptom-group  may  leave  the  case  in 
doubt.  The  probability  increases  with  the  number  of  more  or 
less  characteristic  signs  and  symptoms.  Anemia  with  painful 
digestion  in  a  girl,  presenting  traces  of  blood  repeatedly  in  the 
stools  and  in  the  vomit  should  excite  more  than  a  suspicion. 
Suggestive  signs  may  also  be  given  by  the  mode  of  beginning 
and  the  general  characters  of  the  evolution  of  the  case.  In 
all  the  hypersthenic  diseases  of  the  stomach  the  possibility 
of  the  development  of  an  ulcer  should  not  be  forgotten,  and 
in  all  the  doubtful  and  suspicious  cases  the  general  principles 
of  the  treatment  of  ulcer  should  govern  the  medication 
adopted.  "  Suspicions  which  fall  far  short  of  a  definite  diag- 
nosis," declares  Brinton,  "  may  be  sufficiently  important  to 
dictate  the  whole  plan  of  treatment.  By  treating  these 
doubtful  cases  as  ulcer  of  the  stomach,  we  may  often  cure 
what  we  can  not  diagnose." 

It  is  always  easier  to  make  a  diagnosis  of  ulcer  at  the 
writing-desk  than  at  the  bedside.  Nothing  would  seem  easier 
than  the  recognition  of  a  disease  with  symptoms  and  signs 
possessing  so  many  distinctive  features.  But  the  physician 
is  not  consulted  after  the  clinical  evolution  of  the  disease 
is  complete,  but  while  the  disease  is  beginning  or  running  its 
course.  The  severe  gastric  hemorrhage  may  be  in  the  future, 
and  of  no  possible  use;  or  it  may  be  in  the  past,  and  with 
nothing  to  reveal  its  source  except  the  recollections  of  a  man 
half  frightened  out  of  his  wits  when  it  occurred.  The  pain 
may  not  possess  its  distinctive  features,  and  the  patient's  lack 
of  observation  may  keep  them  in  obscurity  when  they  exist. 
Vomiting  is  a  symptom  of  too  many  diseases  to  be  of  much 
value.  The  same  is  true  of  hyperchlorhydria,  the  detection  of 
which  may  be  prevented  by  the  opposition  of  the  patient  or 
by  the  danger  of  using  the  tube.  When  the  diagnosis  is  not 
made  easy  by  typical  symptoms  and  signs,  a  probable  diag- 
nosis should  be  based  on  a  careful  consideration  of  all  the 
symptoms  and  signs  which  are  present.  In  some  cases  the 
suspicion  of  ulcer  may  be  so  well  founded  as  to  demand  the 
subjection  of  the  patient  to  the  inconvenience  of  a  rest-cure  ; 
in  other  cases  the  walking  treatment  should  be  adopted,  and 
the  result  of  the  therapeutic  test  may  confirm  or  destroy  the 
suspicion. 

A  knowledge  of  the  seat  of  the  ulcer  may  be  of  value  in 
forming  a  prognosis  and   in  imposing  a  stringent  application 


ULCER    OF   THE   STOMACH.  477 

of  a  methodic  cure  so  as  to  avoid  the  probable  dangers  by 
arresting  the  progress  of  the  ulcer  and  by  causing  it  to  heal. 
It  may  also  suggest  the  probable  necessity  of  surgical  inter- 
vention for  the  relief  of  a  constricting  deformity.  But  the  rules 
for  locating  the  ulcer  are  so  untrustworthy  as  hardly  to  enable 
us  to  make  an  intelligent  guess.  After  it  has  formed,  it  is 
easy  to  diagnose  a  pyloric  or  a  cardiac  obstruction  demand- 
ing surgical  treatment.  The  guides  to  the  localization  of  the 
ulcer  lead  just  as  often  wrong  as  right,  and  very  little  trust 
can  be  given  them. 

If  the  ulcer  involve  the  cardia,  the  pain  is  immediate  on 
swallowing,  particularly  after  a  large  bolus  of  solid  food. 
The  cardia  is  very  sensitive  to  the  temperature  of  food.  If 
the  sound  be  passed,  a  severe  pain  behind  the  ensiform 
process  and  extending  to  the  upper  dorsal  spine  and  shoulder- 
blades  is  complained  of  as  soon  as  the  instrument  passes 
the  cardia.  The  stomach  is  often  intolerant,  and  immediately 
ejects  whatever  is  introduced  into  it.  The  signs  of  cardiac 
obstruction  are  more  trustworthy. 

If  the  ulcer  is  located  in  the  pyloric  region,  the  patient  is 
more  comfortable  when  on  the  left  side,  and  the  pain  is 
increased  when  on  the  right  side.  If  the  ulcer  is  adherent  to 
the  liver,  the  pain  radiates  to  the  right  shoulder.  The  pain  is 
supposed  to  begin  later  than  when  the  food  is  more  quickly 
brought  into  contact  with  the  ulcer.  Strong,  visible,  peri- 
staltic waves,  and  delayed  evacuation,  which  indicate  begin- 
ning pyloric  obstruction,  are  of  more  value. 

If  the  ulcer  be  on  the  smaller  curvature,  or  near  it  on  the 
posterior  wall,  hemorrhage  is  frequent.  The  pain  is  relieved 
by  the  sitting  posture  or  by  lying  on  the  left  side,  and  is 
increased  by  lying  on  the  back  or  on  the  right  side.  The 
dorsal  spontaneous  and  pressure  pain  is  marked,  and  is  rarely 
absent  if  peritonitis  (particularly  with  adhesions)  exists. 

If  the  ulcer  is  on  the  anterior  wall,  hemorrhage  is  rare,  per- 
foration is  frequent,  the  pain  is  relieved  by  the  dorsal  position, 
and  is  located  to  the  left  or  lower  down  than  the  usual  point ; 
a  tumor  or  thickening  may  sometimes  be  felt  and  peritoneal 
respiratory  rubbing  may  sometimes  be  detected. 

Differential  Diagnosis. — Several  painful  diseases  resemble 
ulcer  in  their  clinical  expression,  and  make  it  necessary, 
particularly  in  atypical  cases  of  ulcer,  to  search  for  differential 
symptoms  and  signs.  When  the  cardinal  symptoms  of  ulcer 
are  present,  with  their  usual  associations  and  their  distinctive 
features,  the  case  can  be  nothing  but  gastric  ulcer.  Rut  ulcer 
does  not  conform  its  clinical  manifestations  to  the  classical 


478  DISEASES  OF  THE  STOMACH. 

lines  laid  down  in  books,  and  the  practitioner  will  be  con- 
fronted by  difficulties.  The  diseases  most  likely  to  be  con- 
founded with  ulcer  are  gastralgia  nervosa,  adenohypersthenia 
gastrica,  hypersthenic  gastritis  (which  see),  cancer,  displace- 
ment of  the  stomach  with  painful  digestion,  cholelithiasis,  and 
duodenal  ulcer. 

In  both  gastralgia  nervosa  and  in  ulcer  the  pain  is  gastric, 
and  may  be  paroxysmal  and  severe.  But  the  gastralgic 
attacks  are  intermittent,  begin  suddenly,  and  become  rapidly 
intense ;  are  in  no  constant  relation  with  the  taking  of  food, 
or  with  its  quantity  or  quality,  or  with  the  evolution  of 
digestion;  are  unassociated  with  a  disorder  of  secretion;  and 
the  attacks,  extending  alike  through  the  periods  of  digestion 
and  of  functional  repose,  are  separated  by  days  of  normal 
painless  digestion.  The  neuralgic  pain  coincident  with  diges- 
tion may  be  stilled  by  anodal  sedative  galvanization,  but  this 
is  never  true  of  the  pain  of  ulcer.  The  special  pain  of  ulcer  is 
e.xcited  by  food,  particularly  by  solids  and  by  irritants,  and  is 
digestive;  it  is  relieved  by  the  evacuation  of  the  stomach, 
but  never  by  pressure,  and  is  increased  by  movements  and 
calmed  by  repose.  The  epigastric  and  the  dorsal  points  are 
localized,  sharply  limited,  and  persistent.  Digestive  super- 
acidity  is  frequently  present.  In  gastralgia  there  is  never 
hemorrhage,  secondary  anemia,  nor  inanition  ;  but  there  are 
often  neuralgic  pains  in  other  parts  of  the  body.  It  should 
not  be  forgotten  that  gastric  neuralgia  may  be  a  sequel  of 
ulcer. 

Atypical  ulcer  may  be  confounded  with  the  digestive  form 
of  adenohypersthenia  gastrica.  The  two  prominent  symp- 
toms of  this  dynamic  affection  of  the  stomach  are  hyper- 
chlorhydria  and  painful  digestion.  Naturally,  no  doubt  can 
exist  when  there  has  been  a  large  gastric  hemorrhage  or 
repeated  small  gastric  hemorrhages.  The  blood  signs  of 
hemr)rrhagic  anemia  are  very  valuable  in  the  e.xclusion  of  the 
non-hemorrhagic  diseases  of  the  stomach,  provided  the 
source  of  the  hemorrhage  can  be  located  in  the  stomach. 
But  ulcer  is  often  manifested  by  pain  and  by  hyperchlorhy- 
dria,  the  other  primary  and  secondary  signs  and  symp- 
toms being  suppressed.  The  presence  of  any  anatomical 
signs  would  at  once  exclude  the  dynamic  affection,  and  signs 
of  inanition  would  be  in  favor  of  ulcer.  Hyperchlorhydria 
is  not  always  present  in  ulcer,  as  in  the  other  affection 
under  consideration.  But  the  practitioner  may  be  confronted 
by  a  condition  where  a  probable  conclusion  must  be  drawn 
from  the  characteristics  of  the  pain,  which   may  be  sufficient 


ULCER    OF   THE   STOMACH.  479 

to  suggest  the  one  or  to  exclude  the  other.  Pain  increas- 
ing with  the  evolution  of  secretion  and  relieved  by  albu- 
minous foods,  speaks  in  favor  of  adenohypersthenia.  The 
pain  is  acid-produced,  and  is  diminished  by  combining  the 
free  HCl.  The  pain  of  ulcer  is  excited  directly  by  the 
mechanical  and  the  chemical  irritation  of  the  food,  though 
hyperchlorhydria  may  also  be  a  factor  of  its  genesis.  The 
pain  of  ulcer,  being  due  to  combined  influences,  is  never  com- 
pletely relieved  by  the  administration  of  albuminous  foods. 
Other  special  characteristics  of  the  pain  of  ulcer — such  as  the 
relation  to  the  movetnents  of  the  body,  to  the  attitude,  etc. — 
may  be  present.  The  epigastric  and  tender  dorsal  points  of 
ulcer  are  present  during  the  period  of  gastric  repose.  The 
causation,  the  genesis,  and  the  evolution  may  be  in  favor  of 
the  one  or  the  other  disease.  In  some  cases  doubt  can  only 
be  dispelled  by  time,  and  in  the  meanwhile  the  treatment 
suitable  for  the  more  serious  disease  should  be  employed. 

The  physician  is  often  called  upon  to  make  the  differen- 
tiation of  ulcer  and  of  cancer  of  the  stomach.  This  may  be  a 
problem  of  easy  solution,  or  one  that  necessitates  a  close 
study  of  the  distinctive  features  of  the  symptoms  common  to 
the  two  diseases  ;  or  a  search  for  symptoms  and  signs  present 
only  in  the  one  or  in  the  other.  There  may  be  general  features 
and  little  peculiarities  and  associations  which  speak  in  favor 
of  a  benign  or  of  a  malignant  process.  These  minor  points 
are  given  in  the  clinical  descriptions  of  the  two  diseases,  and 
will  often  be  found  of  more  value  at  the  bedside  than  tables 
of  contrasting  generalities.  Some  of  the  more  important  dis- 
tinctive features  will  here  be  brought  together. 

Cancer  is  most  frequent  between  the  ages  of  forty  and  sixty, 
and  is  rare  before  thirty.  Ulcer  is  most  frequent  between 
twenty  and  forty,  but  is  by  no  means  rare  after  this  period. 
The  beginning  of  the*  disease  before  thirty  is  in  favor  of  ulcer, 
but  it  should  not  be  forgotten  that  carcinoma  may  rarely 
occur  before  the  twentieth  year. 

The  beginning  of  carcinoma  is  acute,  and  most  frequently 
without  any  previous  gastric  trouble.  A  disease  of  the 
stomach,  beginning  somewhat  suddenly,  without  appreciable 
cause,  in  a  man  beyond  the  fortieth  year,  is  circumstantial 
evidence  in  favor  of  cancer. 

Ulcer  frequently  begins  insidiously,  with  predisposing  and 
exciting  causes  ;  or  else  suddenly,  with  a  characteristic  cardi- 
nal symptom.  But  it  must  not  be  supposed  that  a  diseased 
stomach  does  not  become  the  seat  of  cancer. 

The  evolution  of  carcinoma  is  rapid,  progressive,  uncon- 


480  DISEASES  OF  THE  STOMACH. 

troUable.  Tlie  disease  kills  in  about  two  years,  and  tlie 
clinical  period  is  about  fourteen  months.  There  are  no  abso- 
lute breaks  in  its  deadly  march,  but  under  proper  treatment 
there  may  be  periods  of  improvement.  Ulcer  is  a  chronic 
disease,  with  periods  of  quiescence  and  self-improvement, 
yieldin<j  often,  as  if  by  charm,  to  well-regulated  treatment.  It 
may  also  be  acute,  but  its  symptoms  and  signs  are  then  all 
the  more  likely  to  be  characteristic,  and  an  early  fatal  termi- 
nation may  occur  in  a  distinctive  manner  from  profuse  hem- 
orrhage or  from  perforation,  and  not  from  auto-intoxication, 
cachexia,  and  inanition.  But  inanition  may  also  develop 
rapidly  in  ulcer,  as  a  consequence  of  the  insufficient  diet,  or 
of  vomiting,  or  of  hemorrhage.  In  cancer,  also,  the  small 
repeated  hemorrhages  may  be  very  pernicious;  but  the 
emaciation  often  continues  in  spite  of  the  retention  of  enough 
food  to  mantain  the  balance  of  nutrition,  because  a  part  is 
lost  by  fermentation  and  by  deficient  utilization,  and  because 
catabolism  is  e.xcessive.  In  ulcer,  however,  inanition  and 
cachexia  may  be  as  pronounced  as  in  cancer,  and  may  be  the 
cause  of  death  ;  but  this  does  not  occur  until  the  disease  has 
lasted  much  longer  than  the  clinical  period  of  carcinoma, 
unless  a  complication  develops. 

Pain  presents  in  the  two  diseases  many  distinctive  features. 
Naturally,  only  the  painful  forms  or  periods  of  carcinoma  and 
ulcer  come  into  consideration  here.  The  pain  of  cancer  is 
not  confined  to  the  digestive  period,  nor  does  it  develop  in 
relation  with  the  evolution  of  secretion  ;  it  is  not  excited  by 
the  taking  of  solid  food,  but  its  intensity  often  increases  after 
food  is  taken  which  easily  undergoes  lactic  acid  fermentation. 
The  pain  is  most  frequently  the  result  of  excessive  acid-pro- 
duction (butyric  and  lactic  acid)  by  bacteria,  but  local  perito- 
nitis and  painful  adhesions  should  not  be  overlooked.  The 
pain  is  sharp,  lancinating,  agonizing,  and  peisists,  and,  in- 
deed, often  is  most  intense  during  the  period  when  the 
stomach  should  be  empty  and  at  rest.  It  is  well  known  that 
stagnation  or  retention  is  nearly  always  present  in  cancer,  and, 
consequently,  the  pain  is  often  due  to  the  irritant  contents. 
But  the  carcinomatous  stomach,  when  empty,  may  also  be  the 
seat  of  severe  spontaneous  pain.  All  these  characteristics  are 
in  marked  contrast  with  those  of  the  special  pain  of  ulcer, 
already  so  minutely  described.  It  is  only  in  exceptional 
cases  that  pain  on  pressure  is  localized,  circumscribed,  and 
so  acute  as  in  ulcer. 

A  profuse  hemorrhage,  with  the  vomiting  of  pure  blood, 
is   rare    in    carcinoma,  the    vomit  commonly    being    "  coffee 


ULCER    OF   THE   STOMACH.  48 1 

grounds  "  in  appearance  and  mixed  with  the  very  acid  and 
sometimes  stinking  contents.  Small  hemorrhages  possess  no 
differential  value,  though  melena  is  much  less  frequent  in 
cancer. 

The  vomiting  of  ulcer  is  easy  and  digestive,  and  occurs  at 
the  climax  of  the  pain,  which  it  relieves.  In  cancer,  vomiting 
may  occur  at  any  moment,  and  may  be  repeated  soon  after 
the  stomach  has  been  thoroughly  emptied,  and  is  usually 
difficult  and  accompanied  by  retching. 

A  tumor  may  be  felt  in  either  disease,  but  is  very  much 
more  frequent  in  cancer.  In  the  one  case  a  very  sensitive 
inflammatory  mass  is  felt,  nearly  always  firmly  adherent  to 
the  surrounding  parts.  The  tumor  of  cancer  is  frequently 
mobile,  nearly  always  much  less  sensitive,  and  often  can  be 
fixed  during  expiration  by  the  examining  fingers.  But  the 
mere  presence  of  a  tumor  is  by  no  means  conclusive,  and 
neither  is  its  absence  very  much  in  favor  of  ulcer. 

Ulcer  and  carcinoma  can  nearly  always  be  distinguished 
with  certainty  by  the  functional  and  the  bacteriological  signs. 
Ulcer  has  only  one  functional  sign,  and  this  is  not  a  symptom 
of  the  ulcer,  but  of  the  associated  adenohypersthenia  or  hyper- 
sthenic gastritis.  Fortunately,  this  one  functional  sign — 
hyperchlorhydria — is  never  found  in  cancer  except  in  the 
very  rare  cases  where  it  is  engrafted  on  an  old  ulcer.  Some- 
times, in  ulcer,  the  hydrochloric  acidity  is  normal,  but  this 
is  very  rarely  so  in  cancer.  Exceptionally,  hypochlorhydria 
is  found  at  some  period  of  ulcer;  but  hypochlorhydria  is 
the  rule  in  cancer.  In  ulcer  there  is  no  fermentation,  nor 
excessive  nor  peculiar  germ  growth,  unless  there  is  retention 
due  to  pyloric  obstruction  or  stagnation  from  motor  insuf- 
ficiency produced  by  adhesions.  But  in  these  complicating 
conditions  hydrochloric  superacidity  is  the  rule,  and  sarcinae 
may  be  found  in  large  quantity  (retention) ;  and  there  is  yeast 
fermentation,  with  the  formation  often  of  large  quantities  of 
gas  in  the  stomach  and  in  the  fermentation  tubes.  The  func- 
tional and  the  bacteriological  signs  of  cancer  are  very  different 
— motor  insufficiency,  diminished  secretion,  characteristic 
bacillary  growth,  and,  chiefly,  lactic  and  butyric  acid  fermenta- 
tion. Lactic  acid  is  never  formed  in  ulcer  after  thorough 
lavage  and  the  oatmeal  test  of  Boas,  but  it  is  so  formed  fre- 
quently and  often  at  an  early  period  in  cancer.  The  functional 
signs  of  cancer  are  persistent;  the  functional  signs  of  ulcer 
may  change  rapidly  under  the  influence  of  sedative  and  pro- 
tecting medication. 

The  displacements  of  the  stomach  (vertical  displacement 
31 


482  D/SEASES  OE  THE  STOMACH. 

and  total  descent)  are  easily  determined  by  their  signs  and 
symptoms.  The  dislocated  stomach  may  become  obstructed 
or  myasthenic,  and  its  mucous  membrane  irritable  or  even 
inflamed.  Under  these  circumstances  there  may  be  stagna- 
tion, superacidity,  and  severe  paroxysmal  digestive  pain. 
The  problem,  then,  to  solve  is  whether  the  displaced  stomach 
is  also  the  seat  of  ulcer. 

The  pain  of  ulcer,  associated  with  a  displacement  of  the 
stomach,  is  often  atypical.  It  is  often  independent  of  the 
quality  of  the  food,  solid  food  being  eaten  without  much  dis- 
comfort. There  may  be  little  difference  in  the  subjective 
symptoms  excited  by  the  digestion  of  a  solid  meal  and  of 
one  composed  exclusively  of  fluids.  The  pain,  which  usually 
occurs  late,  rarely  culminates  in  vomiting. 

The  painful  forms  of  the  dislocations  of  the  stomach  have 
also,  as  a  rule,  a  tender  epigastric  point.  The  discomfort  is 
increased  by  movement  and  is  relieved  by  repose.  Conse- 
quently, in  this  particular  condition  many  of  the  ulcer  char- 
acteristics are  not  available,  for  the  ulcer  may  be  present 
in  the  dislocated  stomach,  with  stagnant  contents,  fermenta- 
tion, and  hydrochloric  superacidity.  In  the  absence  of  any 
of  the  signs  of  hemorrhage,  the  exclusion  or  the  detection  of 
an  ulcer  may  be  impossible.  But  a  hypothesis  may  be  built 
on  a  study  of  the  tender  points.  Those  of  ulcer  have  already 
been  minutely  described.  In  the  painful  dislocations  the 
epigastric  point  is  never  so  sensitive  as  in  ulcer,  and  is  sup- 
posed to  be  due  to  an  irritable  solar  plexus.  The  frequent 
association  of  the  epigastric  tender  point  with  tender  points  to 
either  side  of  and  below  the  umbilicus  makes  this  opinion 
plausible.  Neurasthenic  tender  points  are  also  often  found 
along  the  spine,  including  the  cervical  and  sacral  regions.  If 
only  one  tender  point  is  found  over  the  abdomen,  and  is  located 
in  the  epigastrium,  and  does  not  correspond  in  form  and  area 
with  the  left  lobe  of  the  liver;  if  only  one  tender  point  is 
found  in  the  back,  and  situated  to  the  left  of  the  two  lower 
dorsal  vertebrae — if  both  these  points  are  very  sensitive  and 
persistent,  the  presence  of  an  ulcer  is  very  probable.  In 
ulcer  the  stomach  is  always  beneath  the  tender  point.  The 
tender  point  of  gastroptosis  is  above  the  lesser  curvature,  and 
the  pain  is  not  produced  until  the  pressure  of  the  finger  is 
exerted  on  the  gastrophrenic  ligament.  In  some  cases,  with 
atypical  symptoms  and  signs,  the  diagnosis  or  exclusion  of 
ulcer  is  a  mere  assertion. 

Cholelithiasis  and  gastric  ulcer  often  come  up  for  differen- 
tial diagnosis.     A  profuse  hemorrhage   or  the  detection  of  a 


ULCER    OF  THE   STOMACH.  483 

gall-stone  in  the  feces  would  be  decisive.  But  it  should  be 
remembered  that  the  two  diseases  may  be  coexistent. 

The  attacks  of  gall-stone  colic  are  periodical,  and  are  sepa- 
rated by  intervals  when  an  ordinary  mixed  diet  is  borne  with 
perfect  comfort.  During  the  attack,  however,  the  functions 
of  the  stomach  may  be  reflexly  disturbed.  In  some  cases 
the  attacks  recur  with  very  short  intervals,  and  with  marked 
regularity.  But  during  the  short  interval  one  or  more  mixed 
meals  may  be  painlessly  digested.  The  course  of  ulcer  may 
be  broken  by  anatomical  periods,  but  only  exceptionally,  and 
never  by  short  periods  of  severe  manifestations  and  of  com- 
plete silence. 

The  pain  of  gall-stone  colic  is  independent  of  digestion, 
and  has  its  center  usually  to  the  right  of  the  median  line,  and 
radiates  to  the  right  into  the  back  and  the  right  shoulder. 
There  is  often  a  sensitive  area  to  the  right  of  the  last  dorsal 
vertebra,  and  the  whole  hepatic  region  may  be  sensitive.  If 
epigastric  tenderness  exists,  it  corresponds  in  form  with  the 
usually  unenlarged  left  lobe  of  the  liver.  The  gall-bladder, 
situated  about  two  inches  to  the  right  and  the  same  distance 
above  the  umbilicus,  may  be  exquisitely  sensitive  and  dis- 
tended ;  may  produce  a  visible  tumor,  and  sometimes  peri- 
toneal friction  may  be  detected  during  the  up-and-down 
movements  of  respiration  ;  and,  very  rarely,  the  rubbing  to- 
gether of  gall-stones  may  be  felt.  During  or  soon  after  the 
attack,  particularly  when  the  recurrences  are  frequent,  the 
right  lobe  of  the  liver  is  enlarged,  smooth,  and  sometimes 
tender.  Very  important  differential  signs  are  the  fever  and 
the  jaundice  which  often  accompany  the  attacks  of  gall-stone 
colic.  The  attack  also  begins  without  any  fixed  relation  to  a 
meal,  and  ends  in  a  manner  equally  inexplicable  by  a  sup- 
posed location  of  the  trouble  in  the  stomach. 

The  most  frequent  gastric  trouble  in  cholelithiasis  is  motor 
insufficiency,  which  is  not  a  sign  of  simple  primary  ulcer  ; 
and  gastric  secretion  may  be  excessive  or  continuous.  Hyper- 
chlorhydria  is  about  as  frequent  in  gall-stone  colic  as  in  ulcer, 
but  it  may  subside  between  the  attacks  without  special  treat- 
ment. Whoever  has  watched  the  gastric  functional  signs  in 
the  two  diseases  will  not  put  much  faith  in  their  value  as 
differential  signs. 

The  clinical  expression  of  ulcus  duodeni  is  very  variable 
and  indefinite.  This  utter  lack  of  distinctive  features  is  its 
strongest  characteristic.  Its  irregular  manifestations  are  very 
similar  to  those  of  atypical  gastric  ulcer,  and  it  is  very  seldom 
that    an    opportunity,  when   it    presents    itself,  is  utilized  to 


484  DISEASES  OF  THE  STOMACJI. 

attempt  the  differentiation,  which  nia\'  sonietinics  be  made 
with  probability.  Like  ulcer  of  the  stomach,  tiiat  of  the 
duodenum  may  be  completely  anatomical,  or  latent  up  to  the 
moment  of  a  fatal  hemorrhage  or  of  perforation.  In  the  rest 
of  the  cases  there  may  be  symptoms  which,  on  account  of 
their  location,  characters,  associations,  conditions,  and  gen- 
eral lack  of  distinct  meaning,  may  excite  suspicion.  The 
following  considerations  may  sometimes  render  it  possible 
to  make  a  probable  differentiation. 

Ulcus  duodeni  is  a  much  less  frequent  disease  than  gastric 
ulcer;  it  is  more  frequent  in  the  male  sex;  one-tenth  of  the 
cases  occur  before  the  tenth  year;  it  is  common  after  non- 
fatal extensive  burns  of  the  skin,  and  is  not  produced  by  chlo- 
rosis or  anemia.  The  pain  of  duodenal  ulcer  in  about  one-third 
of  the  cases  is  a  prominent  symptom,  and  is  located  where  the 
right  parasternal  line  crosses  the  right  costal  border;  it  may 
be  excruciating,  and  radiate  over  the  abdomen  ;  it  does  not 
entirely  subside  when  the  stomach  is  empty\  is  not  often  re- 
lieved by  vomiting,  and  may  begin  as  late  as  two  or  three 
hours  after  a  meal  and  continue  during  the  night.  Some- 
times the  taking  of  food  relieves  it,  and  Chvostek  notes  that 
the  paroxysm  of  pain  was  relieved  in  one  of  his  cases  after 
the  ingestion  of  a  glass  of  wine.  If  local  peritonitis  is 
present,  the  pain  may  be  severe  and  continuous,  increased  by 
taking  food,  and  the  duodenal  region  may  be  extremely  sen- 
sitive to  pressure.  A  duodenal  tender  point  exists  in  most 
of  the  clinical  cases,  but  a  dorsal  point  is  seldom  found. 
Vomiting  is  infrequent,  painful  digestion  is  uncommon,  and  in 
a  case  observed  by  Leube  hyperchlorhydria  did  not  exist. 
A  profuse  hemorrhage  occurs  in  about  one-fourth  of  the 
cases,  and  may  produce  both  stormy  hematemesis  and  melena, 
but  melena  alone  is  the  rule.  Icterus  is  sometimes  produced 
if  the  ulcer  is  near  the  opening  of  the  common  duct,  with 
foul,  fatty  stools.  These  signs  and  symptoms  differ  from 
those  of  gastric  ulcer  chiefly  in  their  relative  frequency,  or 
in  peculiarities  which  are  only  exceptionally  present.  Fortu- 
nately, the  treatment  of  gastric  ulcer  is  appropriate  for  both 
diseases. 

Complications. — The  complications  of  ulcer  are  numerous, 
antl  some  are  more  dangerous  than  the  disease  which  has 
caused  them.  Anatomically,  ulcer  is  either  non-perforating 
or  perforating.  At  any  moment  during  its  evolution  ulcer 
may  become  cancerous.  Before  perforation,  the  only  other 
complications  are  local  peritonitis  and  hypersthenic  gastritis. 
After  perforation  there  may  occur  ulceration  of  the  adherent 


ULCER    OF   THE   STOMACH.  485 

parts,  general  peritonitis,  abscess  and  its  consequences.  The 
secondary  oligocythemia,  which  may  be  mild,  severe,  or 
grave,  has  been  described  among  the  symptoms. 

Engrafted  Cancer. — About  five  per  cent,  of  the  cases  of  car- 
cinoma of  the  stomach  develop  in  the  border  or  in  the  cica- 
trix of  an  ulcer.  "  The  edges  undergo  cancerous  degenera- 
tion or  a  fungous  growth  shoots  up  from  the  base,"  wrote 
Brinton,  who  was  the  first  to  notice  this  complication.  No 
other  disease  of  the  stomach  seems  to  form  so  favorable  a 
soil  for  the  development  of  cancer.  The  ulcer,  or  scar, 
seems  to  be  the  point  of  least  resistance  to  the  atypical, 
invading,  and  unconfined  epithelial  proliferation.  Where 
cancer  of  the  stomach  develops  in  such  conditions,  it  always 
selects  the  border  of  the  ulcer  or  the  cicatrix  for  its  location. 
On  the  other  hand,  the  development  of  a  peptic  ulcer  in  the 
part  affected  by  cancer,  or  even  in  the  healthy  part  of  a  can- 
cerous stomach,  has  not  been  observed.  The  ulcer  is  always 
the  primary  disease  in  which  the  cancer  has  become  en- 
grafted. 

The  diagnosis  of  the  complication  during  life  is  most  often 
a  happy  guess,  except  where  a  nodulated  tumor  can  be  felt 
in  the  pyloric  region,  increasing  in  size  from  day  to  day, 
accompanied  by  uncontrollable  and  progressive  emaciation 
and  cachexia,  out  of  proportion  to  the  amount  of  food  eaten 
and  retained.  Hyperchlorhydria  is  the  rule,  and  is  as  persis- 
tent as  that  of  simple  ulcer.  The  functional  and  the  bacterio- 
logical signs  may  not  be  distinctive.  The  detection  of 
secondary  nodules  in  the  liver  would  be  conclusive  in  favor 
of  cancer,  and  the  previous  history  might  reveal  the  exist- 
ence of  the  ulcer  which  has  undergone  malignant  degenera- 
tion. Either  the  ulcer  or  the  cancer  will  be  overlooked,  unless 
the  present  signs  reveal  a  cancer  and  the  previous  history 
an  ulcer.  After  the  development  of  the  carcinoma,  the 
previously  benign  clinical  evolution  becomes  malignant  and 
progressive. 

Plastic  Peritonitis. — A  local  plastic  or  productive  peritonitis 
is  a  very  common  complication  before  perforation  occurs, 
and  may  be  considered  a  conservative  process.  Ulcer  may 
heal  after  perforation  if  a  base  is  supplied  by  an  adherent 
organ  or  muscle  ;  death,  in  the  natural  course  of  events,  is 
almost  certain,  if  the  contents  escape  into  the  general  peri- 
toneal cavity.  But  adhesions  do  not  always  form,  even  after 
the  local  peritonitis  has  long  existed  ;  particularly  if  the  ulcer 
is  located  on  the  anterior  wall,  which  makes  large  excursions 
with  both  movements  of  respiration. 


486  DISEASES  OF  THE   STOMACH. 

The  process  then  can  act  conservatively  only  through 
the  possibly  increased  resistance  against  perforation  made  by 
the  thickened  peritoneum.  At  autopsies,  gastric  adhesions 
are  found  in  about  one-half  the  cases  where  ulcer  has  existed. 
Including  cases  where  plastic  peritonitis  exists  without 
adhesions  forming,  it  may  be  estimated  that  simple  local 
productive  peritonitis  occurs  in  the  majority  of  the  cases  of 
ulcer. 

There  are  no  signs  or  symptoms  by  which  the  complication 
can  be  recognized.  Many  of  the  distinctive  characteristics  of 
the  special  pain  of  ulcer  are  in  reality  due  to  it,  and  it  is 
probably  present  in  all  cases  where  the  tender  points  are 
extremely  sensitive,  and  a  dull,  aching,  deep-seated,  spon- 
taneous pain,  causing  the  patient  evident  anxiety,  persists 
during  the  period  of  gastric  repose.  In  some  cases  peritoneal 
rubbing  may  be  felt,  or  respiratory  friction  sounds  may  be 
heard  over  the  seat  of  the  trouble,  furnishing  the  only  con- 
clusive and  revealing  signs.  Persistent  extension  of  the 
spontaneous  pain  into  distant  or  unusual  parts,  such  as  the 
right  shoulder,  the  lumbar  region,  and  the  precordium,  should 
excite  suspicion.  The  occurrence  of  the  complication  in  a 
recognizable  form  is  a  danger-signal,  for  the  ulcer  already 
extends  in  depth  to  the  peritoneal  layer. 

Perforation. — In  about  four  per  cent,  of  the  cases  of  ulcer  per- 
foration takes  place.  According  to  Lebert,  in  three  to  five  per 
cent,  of  the  cases  perforation  occurs,  and  is  followed  by  abscess 
or  by  general  peritonitis,  and  is  the  cause  of  about  one-fourth  of 
the  deaths  from  ulcer.  According  to  the  statistics  of  Brinton, 
which  were  compiled  from  autopsies  reported  by  various 
authors,  perforation  occurs  in  every  seven  or  eight  cases  of 
ulcer.  However,  fatal  cases  are  more  frequently  reported, 
and  the  statistics  of  Lebert  are  nearer  the  truth.  About  one- 
twelfth  of  all  ulcers  are  located  on  theanterior  wall,  and  sixty 
per  cent,  of  ulcers  so  located  terminate  in  perforation.  But 
perforation  occurs  in  only  two  per  cent,  of  all  other  ulcers  of 
the  stomach.  We  have  found  58  cases  (35  women,  22  men, 
and  one,  sex  not  given)  of  latent  ulcer  scattered  through  litera- 
ture, the  first  manifestation  of  which  was  perforation,  and  in 
43  of  these  cases  the  ulcer  was  located  on  the  anterior  wall. 
We  have  collected  1348  cases  in  which  the  situation  of  the 
ulcer  was  given,  and  find  it  923  times  on  theanterior  wall  and 
425  times  elsewhere.  Weir  and  Foote  report  the  proportion 
as  43  to  17,  and  Comte  as  28  to  15,  in  favor  of  the  anterior 
surface,  in  operated  cases.  Perforation  is  about  three, times 
as  frequent  in  women  as  in  men  (1483  to  461).     The  cases  in 


ULCER    OF   THE   STOMACH.  487 

men  are  scattered  all  along  through  life,  the  average  of  the 
collected  cases  being  about  40.  Four-fifths  of  the  cases  in 
women  occur  before  the  thirty-fifth  year. 

Perforation  of  the  stomach  may  take  place  when  the  viscus 
is  full  or  when  it  is  empty.  If  perforation  occurs  during  dis- 
tention of  the  stomach  with  food  and  gas,  severe  pain  is  the 
first  symptom.  The  pain  is  sudden,  severe,  often  agonizing, 
and  it  does  not  cease  when  the  stomach  is  empty.  The  epi- 
gastric pain  is  quickly  followed  by  distention  of  the  upper 
part  of  the  abdomen,  which  is  rigid,  and  it  is  accompanied  by 
shock  and  by  anxiety,  and  sometimes  by  a  subnormal  "tempera- 
ture. The  pain  may  be  only  dulled  by  an  ordinary  dose  of 
morphin,  but  it  frequently  moderates  spontaneously  after  a 
few  hours.  Vomiting  is  a  symptom  in  more  than  half  of  the 
cases.  The  pulse  is  feeble,  the  breathing  is  superficial,  rapid, 
and  thoracic,  and  the  temperature  soon  begins  to  rise.  Death 
will  occur  from  general  peritonitis  unless  an  operation  is 
performed,  and  an  operation  is  demanded  as  soon  as  possible 
after  the  development  of  these  symptoms  in  the  course  of 
ulcer.  When  the  abdomen  is  opened  gas  escapes,  but  there 
is  no  foul  odor,  though  the  sour  odor  of  the  escaped  gastric 
contents  may  be  perceptible. 

The  stomach  may  be  empty  when  perforation  occurs,  and 
the  pain  is  not  likely  to  be  so  severe  nor  the  shock  so  great, 
nor  peritonitis  so  general  and  rapid  in  its  beginning  and 
course,  as  in  the  cases  where  perforation  takes  place  during 
digestion.  Indeed,  the  peritonitis  may  be  circumvallated  if 
the  patient  is  kept  quiet  and  the  stomach  empty  and  still. 
Recovery  may  take  place  without  an  operation,  but  it  is  the 
rule  for  the  peritonitis  to  become  general  after  a  few  days  of 
deceptive  quietude,  and  eventually  to  take  the  patient  off. 

Ulceration. — Perforation  may  occur  after  adhesions  have 
been  formed.  The  results  of  perforation  under  such  circum- 
stances are  ulceration,  inflammation,  and  abscess  formation 
in  the  adherent  part,  leaving  often  a  fistulous  connection 
with  the  stomach. 

The  ulceration  which  has  eaten  through  the  gastric  wall 
invades  the  adherent  organ  or  part.  When  the  pancreas  forms 
the  base  of  the  ulcer, — and  this  is  most  frequently  the  case, — 
purulent  inflammation  and  abscess  formation  are  infrequent, 
the  tissues  of  this  organ  being  unusually  resistant.  The  ulcer 
heals,  or  eats  its  way  gradually,  by  molecular  death,  into  the 
glandular  structure  or  into  the  excretory  ducts,  producing 
thus  a  pancreato-gastric  fistula.  The  liver  maybe  invaded  in 
the  same  way ;  but  this  organ  is  less  resistant  than  the  pan- 


488  DISEASES  OE  THE  STOMA  CI/. 

creas,  and  the  ulceration,  progressing  eccentrically,  forms  a 
large  ca\'ity,  or  the  process  may  be  walled  in  by  interstitial 
inflammation.  Biit  more  frequently  a  hepatic  abscess  forms, 
which  is  badly  drained  by  its  fistulous  connection  with  the 
stomach.  Ulceration  may  also  form  a  canal  of  communication 
between  the  stomach  and  the  gall-bladder,  between  the 
stomach  and  the  intestines,  and  between  the  stomach  and  the 
external  world,  through  the  abdominal  wall.  The  ulceration 
may  extend  through  adhesions  to  the  spleen,  and  then  com- 
monly produces  a  splenic  abscess.  Another  and  a  very  danger- 
ous route  is  by  way  of  the  diaphragm,  causing,  as  the  morbid 
process  advances,  productive  or  purulent  inflammation,  and 
filling  the  traversed  cavities  with  decomposing  pus  and  gas. 
In  this  way  the  pleural  cavity  (left),  the  pericardium,  the  heart, 
the  mediastinum,  and  the  lungs  may  be  involved.  It  is  ex- 
tremely infrequent  that  these  parts  are  reached  directly  by 
simple  ulceration;  but  far  more  frequently  through  the  media- 
tion of  a  subphrenic  abscess.  During  the  extension  of  the 
ulceration  a  blood-vessel  may  be  encountered,  and  its  wall 
may  be  eroded.     Hemorrhage  is  the  natural  result. 

The  diagnosis  of  these  many  complications  is  made  through 
the  signs  of  ulcer,  of  local  peritonitis,  and  of  adhesions,  and 
through  those  furnished  by  the  secondary  affection  of  the 
particular  organ  or  parts  involved.  The  complications 
may  be  accompanied  by  fever,  but  uncomplicated  ulcer  is 
always  an  afebrile  disease.  The  signs  of  ulcer  and  of  local 
peritonitis  have  already  been  given ;  the  other  diagnostic 
signs  will  be  given  in  the  paragraphs  on  abscess  and  on  the 
sequelae. 

Abscess. — Subphrenic  abscess  is  a  very  serious,  but  fortu- 
nately an  infrequent,  complication  of  ulcer  of  the  stomach. 
Maydl  (1894)  has  collected  in  all  35  cases  of  gastric  origin, 
three  of  these  being  caused  by  carcinoma  and  32  by  ulcer; 
some  of  the  cases  enumerated  by  Nowack  being  thrown  out 
because  the  etiological  diagnosis  was  doubtful.  Brinton 
(1859)  states  that  "there  are  about  20  cases  of  chronic  per- 
forative abscess  on  record."  These  statistics  by  no  means 
include  all  the  cases  of  this  complication,  for  as  a  clinical 
entity  it  is  a  comparatively  recent  disease  (Leyden,  1880), 
the  first  clear  clinical  description  (by  Barlow,  1845)  having 
attracted  little  general  attention.  Cases  (chiefly  found  at 
autopsies)  are  reported  here  and  there  in  medical  literature, 
but  the  complication,  in  its  clinical  and  practical  aspects,  has 
been  best  studied  by  Barlow  (1845).  Bouchard  (1862),  Rigal 
(1874),   Cassy  (F879),   Leyden   (1880),   Nowack    (1881),  and 


ULCER    OF   THE    STOMACH.  489 

Maydl  (1894).  The  monograph  of  Maydl  is  a  masterful  pre- 
sentation of  the  subject. 

Perforation  into  the  peritoneal  cavity,  according  to  Lebert, 
occurs  in  from  three  to  five  per  cent,  of  the  cases  of  ulcer. 
In  some  of  these,  on  account  of  the  minuteness  of  the  open- 
ing, on  account  of  the  degree  of  intragastric  pressure  at  the 
moment  of  perforation,  and  of  the  protection  afforded  by  an 
adjacent  part,  or  other  accidental  circumstance,  the  peritonitis 
is  circumscribed,  and  the  pus  is  walled  in  and  confined  to  the 
abscess  cavity.  Perforation  after  adhesions  have  formed  is 
more  frequent,  and  the  tissue  uniting  the  stomach  to  the 
adjacent  part  may  break  down  or  be  perforated,  and  sub- 
phrenic abscess  results.  The  infection  may  be  conveyed 
along  the  lymphatics,  and  the  abscess  may  form  without  per- 
foration of  the  stomach.  The  complication,  consequently,  is 
not  so  very  infrequent  as  the  small  number  of  authenticated 
cases  would  indicate,  and  its  pathology  and  its  diagnosis 
should  be  more  generally  known,  for  surgical  interference 
gives  the  only  hope  of  cure. 

In  about  one-half  of  the  cases  the  ulcer  is  located  on  the 
lesser  curvature  and  the  posterior  wall ;  more  rarely,  near  the 
cardia  or  on  the  greater  curvature.  The  left  lobe  of  the 
liver,  though  it  be  previously  bound  to  the  stomach  by  adhe- 
sions, offers  little  protection  against  the  development  of  an 
abscess ;  and  in  about  one-tenth  of  the  collected  cases  the 
stomach  was  firmly  adherent  to  the  pancreas,  which  formed 
the  base  of  the  ulcer. 

For  anatomical  reasons,  the  abscess  due  to  ulcer  of  the 
stomach  is  nearly  always  intraperitoneal,  and  located  in  the 
left  concavity  of  the  diaphragm.  It  is  sometimes  located  in 
the  right  hypochondrium,  or  lower  down,  and  separated  from 
the  diaphragm  by  an  intervening  organ. 

In  a  vertical  section  of  the  body,  on  about  a  level  with  the 
ninth  dorsal  vertebra,  two  oval  cavities  are  formed,  surrounded 
on  the  surface  of  the  section  on  all  sides  by  the  diaphragm, 
and  separated  from  each  other  in  the  median  line  by  the  peri- 
cardium, the  esophagus,  and  their  associated  parts.  The 
oval  line  of  the  incised  diaphragm  is  separated  from  the 
abdominal  wall  by  the  pleural  cavities  and  the  lungs.  The 
right  and  larger  cavity  of  the  diaphragm  is  filled  by  the  right 
lobe  of  the  liver,  and  the  left  and  smaller  cavity  by  the 
fundus  of  the  stomach.  As  the  sections  are  made  succes- 
sively lower  down,  the  diaphragmatic  ovals  increase  in 
size  and  the  spleen  appears  on  the  left  side.  Much  earlier 
than  expected,  the   splenic  end   of  the  transverse   colon   and 


490  DISEASES  OF  THE  STOMACH. 

the  splenic  flexure  appear,  and  explain  why  this  viscus  often 
forms  the  lower  boundary  of  the  left  subphrenic  abscess. 

The  serous  covering  of  the  stomach  is  not  complete,  and 
leaves  this  organ  in  immediate  contact  with  the  diaphragm  at 
two  points,  whereby  an  extraperitoneal  subphrenic  abscess 
of  gastric  origin  is  made  possible.  One  of  these  points  is 
situated  immediately  adjacent  to  the  cardia  on  the  side 
toward  the  spleen,  and  the  other  between  the  kidney  and 
the  suprarenal  .capsule,  the  posterior  layer  of  the  lesser 
omentum  leaving  a  small  space  uncovered. 

The  boundaries  of  a  subphrenic  abscess  vary  according  to 
its  location  to  the  right  or  left  of  the  suspensory  or  falciform 
ligament  of  the  liver,  which  separates  the  two  diaphragmatic 
cavities.  The  abscess  in  ulcer  is  seldom  situated  in  the  right 
hypochondrium.  The  exceptional  locations  need  not  be 
minutely  described. 

The  left-sided  subphrenic  abscess  is  nearly  always  bounded 
above  by  the  diaphragm.  The  remaining  constituents  of  its 
wall  depend  on  the  form  and  the  size  of  the  abscess  and  on 
the  relative  location  of  the  organs  in  the  left  h\'pochondrium, 
which  often  are  displaced  or  deformed.  To  the  right  the 
abscess  is  usually  bounded  by  the  diaphragm  and  the  left 
lobe  of  the  liver,  but  it  may  extend  also  as  far  to  the  right 
as  the  falciform  ligament.  Below  the  left  lobe  of  the  liver 
the  stomach,  the  spleen,  and  also  the  colon  and  the  lesser 
omentum,  through  adhesions  to  one  another  and  to  the 
abdominal  wall,  form  the  lower  limit  of  the  abscess  cavity, 
according  to  the  size  of  the  abscess  and  its  extent  down- 
ward. The  limiting  wall  of  the  abscess  cavity  is,  to  a  vary- 
ing depth,  infiltrated  with  pus,  and  here  and  there  are  erosions 
and  often  multiple  perforations. 

The  abscess  cavity  is  filled  with  pus  alone  or  with  pus  and 
gas.  The  pus  is  always  foul,  decomposing,  possessing  often 
a  fecal  odor,  when  the  colon  forms  a  part  of  the  wall.  Mixed 
with  the  pus  is  a  quantity  of  granular  matter,  of  false  mem- 
brane, of  necrotic  tissue  of  the  limiting  organs,  of  bacteria, 
and,  infrequently,  of  gastric  contents.  The  gas  which  is  pres- 
ent in  two-thirds  of  the  gastric  cases  may  be  from  three  or 
even  four  possible  sources.  In  three-fourths  of  the  cases  the 
air  enters  the  abscess  cavity  through  the  communication  with 
the  stomach.  This  is  always  the  source  when  the  abscess  has 
resulted  from  perforation  before  adhesions  have  formed,  and 
in  cases  where  the  communication  was  established  after  the 
formation  of  the  abscess.  The  air  enters  the  abscess  cavity, 
in  the  remaining  fourth  of  the  cases,  through  a  communication 


ULCER    OF   THE   STOMACH.  49 1 

with  a  bronchus.  The  admission  of  air  then  occurs  suddenly, 
and  late  in  the  evolution  of  the  disease.  The  other  possible 
sources  are  through  an  external  fistulous  opening  through  a 
secondary  perforation  of  the  intestines.  In  none  of  the  re- 
ported cases  have  germs  been  found  to  be  the  producers  of 
the  gas.  Gas-forming  micro-organisms  may  form  gas  in  a 
completely  closed  abscess,  but  no  case  of  the  kind  has  been 
observed  in  subphrenic  abscess  complicating  ulcer.  It  is 
probable  that  part  of  the  gas  in  most  of  these  abscesses  is  a 
decomposition  product. 

The  complications  of  a  subphrenic  abscess  are  numerous. 
Perforations  into  the  gall-bladder,  the  colon,  and  the  pericar- 
dium are  extremely  rare.  But  pericarditis  without  perforation 
is  more  frequent,  and  may  be  dry,  exudative,  or  purulent, 
the  inflammation  being  propagated  by  contiguity.  In  one- 
seventh  of  the  cases  of  abscess  occurring  as  a  complication 
of  ulcer  the  lung  is  invaded  and  a  bronchial  communication 
is  established. 

The  diaphragmatic  and  the  pulmonary  layers  of  the  pleura 
adhere,  and  purulent  pneumonitis  and  necrosis  follow  perfora- 
tion, the  abscess  of  the  lung  communicating  eventually  with 
a  bronchus.  A  circumscribed  pneumonia  may  also  be  pro- 
duced by  extension  from  an  inflamed  pleura. 

Possibly,  a  little  more  frequently  the  pleural  cavity  is 
perforated,  and  the  contents  of  the  two  cavities  below  and 
above  the  perforated  diaphragm  are  the  same.  Whenever 
the  diaphragm  forms  a  part  of  the  wall  of  the  abscess, — and 
it  is  rarely  otherwise, — pleurisy  without  perforation  is  nearly 
always  present  at  an  early  date,  and  may  be  pseudomem- 
branous, exudative  (with  or  without  blood),  or  purulent. 

The  diagnostic  signs  and  symptoms  may  be  divided  into 
two  classes — those  produced  by  the  abscess  and  those  pro- 
duced by  the  primary  disease  of  which  the  abscess  is  a  com- 
plication. Accordingly,  the  twofold  object  is  the  detection 
of  the  subdiaphragmatic  abscess  and  the  discovery  of  its 
cause. 

The  signs  and  the  symptoms  which  reveal  the  existence  of 
an  abscess  beneath  the  diaphragm  are  : 

1.  The  signs  and  the  symptoms  of  the  development  of  an 
abscess  in  the  epigastric  or  the  hypochondriac  regions. 

2.  The  nature  and  the  evolution  of  the  diseases  developing 
in  consequence  of  the  abscess. 

3.  The  position  of  the  diaphragm  as  revealed  by  inspection. 

4.  A  cavity  containing  gas  located  beneath  one  containing 
fluid. 


492  DISEASES  OF  THE   STOMACH. 

5.  Removal,  by  puncture  at  different  levels,  of  fluid  pos- 
sessing different  qualities. 

6.  The  increased  pressure  to  which  the  fluid  is  subjected 
during  inspiration. 

7.  Certain  physical  signs. 

The  subphrenic  abscess  of  ulcer  develops  rapidly  or  insidi- 
ously. If  it  be  the  result  of  perforation  before  adhesions 
have  formed,  the  sudden  beginning  is  marked  by  severe  epi- 
gastric pain  and  tenderness,  with  more  or  less  shock,  and 
sometimes  a  rigor  and  a  slight  elevation  of  the  temperature. 
The  diaphragm  and  the  upper  part  of  the  abdominal  wall  are 
held  rigid,  so  as  to  avoid  the  pain  due  to  movements.  Nausea 
is  common,  but  vomiting  is  very  infrequent.  Hiccup  and 
pain  on  pressure  over  the  course  of  the  phrenic  nerve  are 
sometimes  present,  and  may  be  due  to  the  diaphragmatitis. 
The  abdomen  may  be  but  slightly  sensitive  on  pressure,  or 
may  be  exquisitely  tender,  particularly  over  the  region  of  the 
peritonitis,  where  the  physical  signs  of  peritoneal  rubbing  or 
friction  may  exist.  After  a  day  or  two  the  symptoms  become 
localized ;  the  lower  abdomen  is  no  longer  distended  or 
tender  ;  but,  in  marked  contrast  therewith,  the  upper  abdomen, 
particularly  over  the  site  of  the  abscess,  is  swollen  and  sensi- 
tive, and  if  the  pus  is  in  contact  with  the  parietal  peritoneum, 
subcutaneous  edema,  extending  from  the  hypochondrium  into 
the  back,  may  develop  The  bowels  may  be  constipated,  but, 
as  a  rule,  move  spontaneously  or  after  a  laxative  if  the  colon  is 
not  involved  by  the  limiting  peritonitis. 

The  beginning  may  be  insidious,  particularly  where  there 
has  been  no  perforation,  or  perforation  after  the  formation  of 
adhesions.  The  spontaneous  and  the  pressure  pains  of  ulcer 
are  no  longer  localized,  but  develop  over  a  new,  and,  for  simjile 
ulcer,  an  unusual,  region.  The  effort  to  immobilize  the  parts  is 
evident  in  the  rigidity  of  the  trunk  and  in  the  shallow  thoracic 
breathing.  There  may  be  slight  chills,  with  increase  of  the 
dull  or  the  aching  pain  and  the  tenderness,  and  with  slight 
fluctuations  of  the  temperature.  All  these  symptoms,  occur- 
ring in  the  course  of  ulcer,  should  immediately  excite  sus- 
picion. If  the  abscess  be  situated  superficially  there  may  be 
a  well-marked  area  of  dullness  (only  pus)  where  normally  it 
should  not  be  found  ;  or  in  the  usual  position  on  the  back, 
assumed  by  the  patient,  the  percussion  note  is  tympanitic,  and 
the  examination  should  then  be  repeated  in  a  sitting  posture, 
and  on  the  side;  and  it  should  be  observed  whether  an  area 
of  dullness  appears  where  tympanicity  before  e.xisted  (pus 
and   gas).     The  subsequent  course  and  symptoms  are  very 


ULCER    OF   THE   STOMACH.  493 

variable,  partly  those  of  the  abscess  (emaciation,  hectic  fever, 
etc.),  but  chiefly  those  of  the  diseases  caused  by  it,  death 
occurring  early  or  after  a  long  illness. 

A  very  important  sequence  of  diagnostic  value  is  the  de- 
velopment of  the  secondary  diseases  of  the  thoracic  organs 
after  the  abdominal  trouble  has  been  in  activity  for  a  length  of 
time.  This  fact  fixes  clearly  the  etiological  relation  of  the 
abscess  to  the  pleurisy,  to  the  pneumonitis,  and  to  the  pericar- 
ditis. For  a  time  there  are  no  expectoration,  no  cough,  and 
no  physical  signs  of  thoracic  disease.  The  disease  of  the  lungs 
and  the  pleurse  develop  from  below  upward.  In  one  series  of 
cases  occurs  diaphragmatic  pleurisy,  adhesion  of  the  base  of 
the  lung  to  the  diaphragm,  pneumonia  of  the  lower  lobe,  and 
possibly  bronchial  perforation  with  profuse  purulent  expector- 
ation— no  history  or  signs  of  bronchitis,  of  bronchiectasis, 
or  of  phthisis.  In  another  series  of  cases  are  found  an 
upward-extending  pleurisy,  empyema,  or  pyopneumothorax. 
An  ulcer  of  the  stomach,  followed  or  accompanied  by  the 
local  signs  and  symptoms  of  purulent  inflammation  in  either 
(rarely  the  right)  hypochondriac  region,  and  invasion  of  the 
thorax  later  by  purulent  inflammation,  always  most  intense 
at  the  base,  form  a  sequence  strongly  in  favor  of  the  existence 
of  a  subphrenic  abscess  as  a  link  in  the  chain  of  evolution. 

The  existence  of  the  secondary  thoracic  disease  compli- 
cates the  condition  but  makes  the  diagnosis  easier.  This  is 
particularly  true  when  the  abscess  cavity  contains  gas.  "  The 
circumstances  of  the  air  being  below  the  fluid  in  the  chest,  and 
the  improbability  of  the  pneumothorax  being  completely  sepa- 
rated by  a  false  membrane  from  a  large  efl"usion  into  the 
pleural  cavity  on  the  same  side,"  was  given  by  Barlow  as  one 
of  the  important  signs  of  a  subphrenic  abscess.  This  brings 
up  one  of  the  most  important  points  in  the  diagnosis — the 
location  of  the  diaphragm  above  or  below  the  collection  of 
pus  or  of  pus  and  gas. 

The  movements  of  the  diaphragm  are  often  visible,  and  by 
inspection  the  position  of  this  muscle  may  be  located  by  the 
line  of  depression  which  moves  up  and  down  with  respiration. 
In  subphrenic  abscess  the  diaphragm  is  higher  on  the  dis- 
eased than  on  the  healthy  side  of  the  chest;  its  respiratory 
excursions  may  be  very  short,  or  it  may  be  fixed  by  adhe- 
sions or  almost  completely  destroyed  by  purulent  inflamma- 
tion. 

The  removal  by  acupuncture,  at  different  levels,  of  fluid  of 
totally  different  qualities,  or  on  the  same  level  but  at  different 
depths,  may  be  an  important  diagnostic  sign.      But  this  is  an 


494  DISEASES  OF  THE  STOMACH. 

untrustworthy  sign,  and  every  precaution  should  be  taken  in 
order  to  be  sure  that  one  specimen  is  obtained  from  above 
and  tlie  other  from  below  the  diaphragm.  Naturally,  if  both 
specimens  consist  of  the  same  kind  of  pus,  no  conclusion  can  be 
drawn  therefrom.  If  gastric  contents  are  mixed  with  the  pus, 
a  connection  of  the  pus  cavity  with  the  interior  of  the  stomach 
is  demonstrated  ;  but  if  it  be  freely  connected  with  the  interior 
of  the  stomach,  the  abscess  cavity  will  also  contain  gas.  Sac- 
culated pleurisN'  and  empyema  are  as  frequent  as  subphrenic 
abscess,  and  it  is  seldom  that  this  double  puncture  sign  can 
have  much  differential  value. 

Great  importance  has  been  given  by  Pfuhl  to  the  relation 
of  the  changes  of  pressure  in  the  cavity  to  inspiration  and  to 
e.Kpiration.  Jaffe  suggests  that  instead  of  using  a  manometer, 
the  changes  in  the  strength  of  the  current  running  through  a 
cannula  be  observed.  If  the  flow  is  greater  during  inspiration 
than  during  expiration,  the  abscess  is  in  all  probability  located 
below  the  diaphragm. 

Certain  physical  signs  may  have  a  differential  value,  but  are, 
possibly,  present  only  when  the  cavity  contains  air.  These  two 
signs  are  amphoric  br^thing  and  metallic  tinkle  and  bubbling, 
heard  low  down  below  where  the  diaphragm  is  normally 
attached  or  is  situated  in  the  particular  case.  The  signs  gain 
immensely  in  value  if  above  them  there  is  a  zone  of  dullness, 
with  no  breath  sounds  nor  vocal  fremitus. 

Before  the  organs  in  the  thoracic  cavity  have  become 
involved  the  diaphragm  is  pushed  up,  and  moves  less  during 
respiration  than  on  the  healthy  side.  There  are  no  abnormal 
auscultatory  signs  over  the  lung  if  the  subphrenic  abscess 
contains  no  gas  ;  but  the  region  over  the  abscess  may  be  dull 
or  tympanitic,  this  latter  sign  being  attributable  to  the  air- 
distended  stomach  in  contact  with  the  pus.  The  normal 
auscultatory  signs  cease  suddenly  when  this  area  is  reached. 
If  the  subphrenic  abscess  contain  much  gas,  amphoric 
breathing  and  metallic  tinkle  should  be  heard,  and  also  suc- 
cussion  sounds.  The  heart  is  pushed  up,  but  is  not  much 
displaced  to  the  right. 

After  the  disease  has  crossed  the  diaphragm  there  may  be 
pleurisy,  and  there  is  no  physical  sign  of  differential  value, 
unless  the  abscess  cavity  contains  gas,  which  will  be  discov- 
ered below  fluid;  or  there  may  be  pyopneumothorax,  but 
without  a  history  of  a  disease  of  the  lungs  to  cause  it;  or, 
again,  the  lungs  may  be  perforated,  and  the  expectoration 
and  the  physical  signs  of  the  purulent  pneumonitis,  develop- 
ing from  below  upward,  will  be  found,  in  addition  to  those 
furnished  by  the  abscess  beneath  the  diaphragm. 


ULCER    OF   THE   STOMACH.  495 

The  etiological  diagnosis  is  dependent  on : 

1.  The  clinical  history  revealing  a  particular  disease  which 
preceded  the  development  of  the  abscess,  and  which  is  known 
to  be  a  cause  of  subphrenic  abscess. 

2.  The  location  of  the  abscess. 

3.  The  contents  of  the  abscess. 

Maydl  divides  the  etiological  diseases  into  12  groups: 
Stomach  (35  cases),  intestines  (13  cases),  appendicitis  (25 
cases),  echinococci  (17  cases),  traumatism  of  the  abdomen 
(18  cases),  liver  (20  cases),  perinephritis  (11  cases),  metastatic 
abscess  (11  cases),  open  wounds  (6  cases),  caries  of  rib  (3 
cases),  thoracic  diseases  (9  cases),  and  other  causes  (i  i  cases). 
From  these  statistics  it  will  be  seen  that  about  one-fifth  of  all 
cases  are  of  gastric  origin,  and  of  the  gastric  cases  about 
95  per  cent,  result  from  ulcer.  The  signs  and  the  symptoms 
of  these  causative  diseases  should  be  sought  for  in  the  clini- 
cal history  and  in  the  examination. 

The  location  of  abscess  due  to  appendicitis,  to  perfora- 
tion of  the  intestines,  or  to  disease  of  the  gall-bladder  is 
almost  without  exception  on  the  right  side.  On  the  contrary, 
the  abscess  due  to  ulcer  occurs  almost  exclusively  on  the 
left.  Maydl  gives  29  on  the  left,  two  on  the  right,  and  two 
on  both  sides.  In  about  one-third  of  the  cases  caused  by 
appendicitis  and  intestinal  perforation  the  abscess  cavity  con- 
tains gas.  The  presence  of  gas  is  noted  in  five-sevenths  of 
the  gastric  cases  collected  by  Maydl. 

A  subphrenic  abscess,  preceded  by  gastric  symptoms,  but 
by  none  of  the  characteristic  signs  or  symptoms  of  the  other 
etiological  diseases,  located  in  the  left  hypochondrium  and 
containing  gas,  is  due  to  a  perforating  ulcer  of  the  stomach. 

SeqiielcE  of  Ulcer. — Clinically,  ulcer  terminates  in  a  cure, 
in  death,  or  in  chronic  invalidism.  Considered  as  an  ana- 
tomical process,  ulcer  is  either  perforating  or  non-perforat- 
ing. The  non-perforating  ulcer  may  heal  with  or  without 
deformity,  with  or  without  adhesions.  Perforation  may  occur 
before  or  after  adhesions  have  formed.  If  it  takes  place 
before  adhesions  unite  the  stomach  to  adjacent  parts,  there 
results  either  general  peritonitis  or  local  peritonitis  and 
abscess,  which  latter  may  eventually  produce  a  fistula.  If 
adhesions  already  exist,  the  result  may  be  healing,  or  a  fis- 
tula, 'or  abscess  with  its  many  possibilities.  Briefly,  the 
sequeljE  of  ulcer  are:  (i)  Adhesions;  (2)  fistulae ;  (3)  de- 
formities. 

I.  Adhesion  of  the  stomach  to  adjacent  parts  is  a  very 
common  sequel  of  ulcer,  forming  either  before  or  after  per- 


496  DISEASES  OF  THE   STOMACH. 

foration.  There  are  no  characteristic  symptoms  or  signs  by 
which  the  condition  can  be  recognized.  It  must  not,  liow- 
ever,  be  supposed  tliat  adhesions  produce  no  symptoms,  for 
the  pain  and  the  uncomfortable  and  indefinite  sensations 
excited  by  the  distention  and  tlie  peristalsis  of  the  stomach, 
and  occurring  after  the  ulcer  is  healed,  should  be  attributed 
to  adhesions. 

2.  FistiiUe  are  rare  sequels  of  ulcer.  The  most  common 
are  gastro-intestinal  and  gastro-external.  The  diagnosis  of 
the  latter  presents  no  difficulty.  If  the  cavities  of  the  stom- 
ach and  the  colon  be  united,  the  result  is  likely  to  be  starva- 
tion, on  account  of  the  small  intestine  being  excluded  from 
digestion ;  but  this  exclusion  is  not  complete  unless  the 
orifice  of  communication  is  large.  Fecal  vomiting,  should 
it  occur,  would  e.xcite  suspicion  of  the  existence  of  the  fistula, 
and  the  character  of  this  fecal  matter  might  give  some  clue  to 
its  involving  the  colon  or  the  small  intestine.  If  the  per- 
foration is  in  the  colon,  the  appearance  in  the  stomach  of  a 
colored  or  easily  recognizable  fluid  introduced  into  the  colon 
establishes  the  diagnosis,  the  introduced  fluid  being  removed 
from  the  stomach  by  the  tube.  Or  the  rapid  passage  of  the 
contents  of  the  stomach  into  the  colon  would  arouse  sus- 
picion. Communication  with  the  bile-passages  would  open 
a  way  for   the  constant  entrance  of  bile  into  the  stomach. 

3.  The  deformity  resulting  from  the  loss  of  substance  and 
from  the  contraction  of  the  scar  affects  either  the  wall  of  the 
stomach  or  one  of  the  two  orifices.  The  deformities  may 
exist  in  many  varieties  and  degrees,  some  compromising  the 
motor  function  very  little  or  not  at  all  and  others  producing 
stagnation,  retention,  or  even  complete  obstruction. 

The  deformities  of  the  wall  are  difficult  to  recognize  during 
life,  and  the  signs  and  the  symptoms  are  the  result  of  the 
insufficiency  of  the  motor  function.  Stagnation  or  retention 
without  either  myasthenia  or  supersecretion  can  be  due  only 
to  obstruction  or  to  a  deformity  of  the  gastric  wall.  The 
two  common  deformities  of  the  wall  are  the  hour-glass  con- 
striction and  the  shortening  of  the  lesser  curvature  so  as  to 
bring  the  cardia  and  the  pylorus  closer  together.  The  latter 
condition  is  not  likely  to  be  even  suspected  during  life,  but 
it  may  be  a  cause  of  stagnation  or  even  of  retention.  The 
hour-glass  stomach,  or  the  division  of  the  viscus  into  two 
communicating  cavities  by  a  constriction,  may  be  congenital 
or  inherited,  or  may  be  due  to  dissociated  and  unequal  con- 
traction of  the  muscular  layer.  This  "physiological"  divi- 
sion of  the  stomach  into  two  cavities  by  muscular  contraction 


ULCER    OF   THE   STOMACH.  497 

only  occurs  during  violent  peristaltic  effort,  and  in  the  other- 
wise normal  stomach  is  a  symptomless  condition.  It  is  not 
so  with  the  cicatricial  hour-glass  stomach,  the  constriction 
being  persistent,  the  communicating  orifice  sometimes  very 
small,  and  the  mechanical  work  very  imperfectly  done.  The 
signs  of  this  deformity  which  aid  in  its  recognition  are  not 
very  characteristic.  If  the  abdominal  wall  be  thin  and  flaccid, 
inflation  of  the  stomach  would  make  the  peculiar  deformity 
evident  on  inspection  and  palpation.  If  the  communicating 
orifice  be  small,  the  peristaltic  auscultatory  intragastric  sounds 
would  locate  the  constriction,  which  should  not  be  con- 
founded with  the  spurting  pyloric  sounds  heard  at  another 
point.  The  alternate  relaxation  and  contraction  of  the 
pylorus,  which  may  sometimes  be  felt  during  digestion, 
would  aid  in  the  recognition  of  the  pylorus.  Another  sign 
is  obtained  during  lavage  of  the  stomach.  The  cardiac  cavity 
having  been  thoroughly  washed  out,  during  the  continuance 
of  lavage  the  clear  water  suddenly  becomes  mixed  and 
cloudy  with  gastric  contents.  To  detect  and  to  control  this 
sign,  which  can  only  be  present  under  special  conditions,  the 
lavage  should  be  made  during  gastric  digestion,  and  when 
the  water  comes  away  clear  the  contents  of  the  pyloric  cavity 
should  be  massaged  through  the  communicating  orifice  and 
removed  by  the  tube.  The  existence  of  the  constriction 
may  be  demonstrable  by  the  balloon  sound  of  Kuhn.  Still 
another  sign  is  one  first  noted  by  Jaworski.  This  is  an  in- 
ability to  withdraw  anything  from  the  stomach  when  splash- 
ing can  be  demonstrated  in  it.  The  fluid  and  the  gas  to 
which  the  splashing  is  due  are  in  the  pyloric  division.  The 
physical  signs  of  this  deformity  should  be  sought  for  in  all 
cases  of  motor  insufficiency  following  ulcer. 

Obstruction  of  the  pylorus  and  cardia  are  the  most  frequent 
and  serious  sequels  of  ulcer.  These  diseases  are  described 
in  another  chapter. 

Prognosis. — Ulcer  is  a  dangerous  disease,  and  the  prognosis 
should  be  very  guarded.  Brinton  gives  the  high  mortality  of 
50  per  cent.,  which  includes  death  during  the  course  of  ulcer 
from  intercurrent  diseases.  About  20  per  cent,  of  the  clini- 
cal cases  die,  but  this  high  mortality  can  be  reduced  one-half 
by  consistent  methodical  treatment.  The  death-rate  of  ulcer 
is  still  less,  for  the  purely  anatomical  form  is  not  rare,  and 
gets  well,  or  is  counted  only  when  fatal,  since  the  latent  fatal 
cases  are  included  in  the  mortality  reports.  The  death-rate 
of  all  cases  of  ulcer  which  receive  treatment  is  less  than 
ten  per  cent. 
32 


498  DISEASES  OF  THE  STOMACH. 

Ulcer  is  a  treacherous  disease,  and,  however  mild  it  may  be, 
a  guarded  opinion  should  be  given.  The  course  of  the  dis- 
ease is  beset  with  danger  and  with  possibly  fatal  accidents. 

The  probability  of  healing  increases  with  the  reparative 
power  of  the  individual  organism.  Healthy  nutrition,  a  vigor- 
ous nervous  system,  rich  blood,  and  good  circulation  are 
favorable  influences.  The  prognosis  is  also  better  when  the 
patient  gets  early  and  proper  treatment.  Unfortunate  cir- 
cumstances may  render  it  impossible  to  carry  out  a  strict 
rest  and  diet  cure,  and  the  mortality  is  more  than  doubled  by 
food  of  bad  quality,  by  forced  work,  and  by  unhygienic  quar- 
ters. 

The  probability  of  death  increases  with  the  depth  of  the 
ulcer.  The  blood-vessels  increase  in  size  from  the  surface  of 
the  mucous  membrane  to  where  they  empty  into  the  loops  of 
small  arteries;  and  the  greater  the  depth  of  the  ulcer,  the 
more  likely  is  the  hemorrhage  to  be  profuse.  Another  dan- 
ger-point is  reached  when  the  ulcer  has  eaten  down  to 
the  peritoneum,  and  opens  up  the  possibility  of  adhesions, 
abscess,  perforation,  general  peritonitis,  and  other  complica- 
tions. 

The  location  of  the  ulcer,  where  this  can  be  made  out,  is 
another  guide.  Ulcer  of  the  anterior  wall  is  very  prone  to 
perforation,  and  when  near  the  orifices  of  the  stomach  may 
leave  obstruction  as  a  sequel. 

The  precxistence  of  advanced  hypersthenic  gastritis  makes 
the  future  dark.  This  disease,  be  it  the  cause,  or  the  acci- 
dental association,  or  the  result  of  ulcer,  is  an  obstacle  to 
healing.  The  persistence  of  symptoms  and  signs  due  to  this 
form  of  gastritis,  in  spite  of  proper  methodical  treatment,  is 
an  unfavorable  sign.  Grave  is  the  outlook  when  stagnation 
•or  retention  exist  in  consequence  of  myasthenia  or  of  obstruc- 
tion ;  and  chronic  invalidism  is  a  very  probable  sequel  wlien 
a  tumor  due  to  perigastritis  can  be  felt. 

Treatment. — Something  can  be  done  toward  the  cure  of 
ulcer  by  the  removal  or  the  treatment  of  its  cause.  The 
destructive  lesion  persists  after  the  influences  that  generated 
it  are  no  longer  active.  The  predisposing  and  the  exciting 
causes  should  receive  attention,  both  with  a  view  to  prevent- 
ing a  recurrence  of  the  disease  and  to  securing  conditions 
essential  to  the  cicatrization  of  the  ulcer.  The  anemia  should 
be  treated  and  the  hyperchlorhydria  should  be  controlled. 

The  indications  to  be  met  by  the  methodical  treatment  of 
ulcer  are  very  clear,  and  fortunately  the  remedies  employed 
are  usuallv  sufficient  and  effective.     Ulcer,  as  soon  as  it  is 


ULCER    OF   THE   STOMACH.  499 

recognized,  should  receive  immediate  and  careful  attention, 
for  it  is  a  disease  which  endangers  life,  and  delays  and  com- 
promises are  inadmissible.  Expectant  treatment  is  a  great 
blunder,  for  simple  ulcer  in  a  vigorous  adult  has  no  "  innate 
tendency  to  heal,"  and  the  grave  accidents  which  are  too  often 
the  heralds  of  coming  death  occur  somewhat  regardless  of 
the  age,  the  constitution,  and  the  general  state  of  nutrition. 
The  treatment  must  in  every  case  be  immediate,  methodical, 
and  sufficiently  vigorous  to  be  effective.  A  compromise  may 
mean  death  or  irreparable  injury. 

The  general  indications  are:  (i)  To  protect  the  stomach 
and  the  lesion  against  all  sorts  of  irritation  ;  (2)  to  give  the 
stomach  functional  rest;  (3)  to  maintain  nutrition;  (4)  to 
treat  the  gross  symptoms  ;  (5)  to  treat  the  complications. 

The  means  employed  to  meet  these  indications  are 
hygienic,  dietetic,  and  medicinal.  The  treatment,  being  also 
protective,  consists  in  part  in  avoiding  injury.  The  remedies 
employed  are  chiefly  medical,  for  it  is  the  business  of  the 
physician  to  treat  ulcer.  But  some  of  the  accidents,  compli- 
cations, and  sequelae  may  demand  the  aid  of  the  surgeon. 

To  obtain  the  cicatrization  of  an  external  open  wound, 
protection  against  irritation  and  immobilization  are  essential, 
while  every  precaution  is  being  taken  to  secure  asepsis.  The 
ulcer  should  be  kept  clean,  still,  and  protected,  and  its  walls 
should  be  maintained  in  close  apposition.  Intragastric  asepsis 
is,  of  course,  a  chimera,  and  fortunately  unnecessary,  inas- 
much as  simple  ulcer  of  the  stomach  progresses  by  molecular 
necrosis  without  pus  formation  or  excessive  inflammatory 
reaction.  But  the  walls  of  both  the  non-perforating  and  the 
perforating  ulcer  do  get  infected;  and  an  effort  to  keep  the 
contents  of  the  stomach  sweet,  and  the  ulcer  as  free  as  pos- 
sible from  purulent  infection,  would  not  be  unnecessarily  made. 

It  is  only  an  ordinary  precaution  to  keep  the  nose,  the 
mouth,  and  the  throat  clean,  and  to  prevent  the  swallowing 
of  purulent  discharges.  But  the  surgical  principles  of  more 
importance  in  the  treatment  of  ulcer,  but  capable  of  only 
imperfect  application,  are  immobilization  and  protection 
against  mechanical,  chemical,  and  thermal  irritation. 

Partial  immobilization  of  the  stomach  can  be  obtained  by 
rest  in  bed  and  by  keeping  the  organ  perfectly  empty.  This  is 
a  favorable  condition  for  the  healing  of  the  ulcer,  although  the 
ulcer  may  cicatrize  under  conditions  much  less  favorable.  All 
convulsive  movements  of  the  diaphragm — coughing,  laugh- 
ing, hiccup — should  be  controlled  ;  and  all  effort  or  strain- 
ing should  be  avoided.     This  course  of  conduct  not  only  aids 


500  DISEASES  OF  THE  STOMACH. 

healing,  but  also  gives  some  protection  against  such  accidents 
as  hemorrhage  and  perforation.  Rest  in  bed  is  ordinarily  an 
essential  part  of  the  treatment,  and  the  so-called  "  walking 
treatment "  of  ulcer  is  an  almost  inadmissible  compromise. 
As  a  rule,  it  is  not  necessary  to  keep  the  patient  in  bed  longer 
than  two  or  three  weeks,  after  which  time  the  cure  may  be 
completed  by  a  free  use  of  the  lounge.  Where  there  is  either 
perigastritis  or  hemorrhage,  or  signs  and  symptoms  indi- 
cating that  the  ulceration  is  progressive,  absolute  rest  in  bed 
should  be  enforced.  This  rest  cure  is  beneficial  in  many  ways. 

The  mechanical  effect  of  rest  is  evident,  and  is  favorable  to 
healing;  it  is  also  a  precaution  against  hemorrhage,  perfora- 
tion, and  the  extension  of  perigastritis.  But  a  no  less  im- 
portant result  is  diminution  of  the  needs  of  nutrition.  The 
body  requires  much  less  nutriment  when  in  a  state  of 
repose  than  when  in  activity.  This  saving  represents  so 
much  less  digestive  work  to  be  done,  and  makes  it  easier 
to  maintain  the  balance  of  nutrition  on  the  small  quantity  of 
unirritating  food  which  it  is  possible,  in  ulcer,  to  give  without 
injury. 

The  mucous  membrane  of  the  stomach  is  exposed  to  many 
forms  of  irritation.  In  ulcer,  the  influence  of  extremes  of 
temperature  seems  to  be  very  injurious.  The  food  and  drinks 
should  be  neither  very  cold  nor  very  hot,  but  as  nearly  luke- 
warm as  possible  without  being  distasteful.  Nothing  mechan- 
ically irritating  should  be  swallowed,  and  this  necessitates  a 
fluid  diet,  combined  or  not  with  completely  digestible  and 
nutritive  solids  in  a  fine  state  of  subdivision.  All  drugs  must 
be  excluded  which  irritate  the  mucous  membrane.  The  diet 
should  contain  nothing  that  is  chemically  irritating,  nor  which 
remains  long  in  the  stomach.  The  secretion  of  the  stomach, 
on  account  of  its  frequent  excessive  acidity,  in  ulcer  is  a 
chemical  irritant;  so  nothing  should  be  given  that  excites 
secretion,  and  the  hydrochloric  acid  should  be  at  once  com- 
bined or  neutralized,  and  never  left  free. 

The  protection  of  the  stomach  against  injurious  irritation, 
then,  can  only  be  secured  by  a  very  strict  and  proper  diet,  by 
the  exclusion  of  most  drugs,  and  by  the  neutralization  of  the 
free  acidity  or  by  exclusive  rectal  feeding.  Proper  alimenta- 
tion is  of  the  greatest  importance,  and  the  diet  will  be  first 
considered. 

Milk  is  not  only  a  valuable  food,  but  also  exerts  a  remedial 
influence  in  ulcer.  Where  milk  is  well  borne,  the  dietetic 
treatment  in  the  beginning  is  an  exclusive  milk  cure.     This 


ULCER    OF   THE   STOMACH.  50I 

food,  when  properly  given,  fulfils  admirably  the  requirements 
of  a  nutritive  remedy.  It  is  unirritating,  combines  rapidly 
the  secreted  HCl,does  not  excite  secretion  excessively,  being 
normally  digested  without  leaving  more  than  a  mere  trace  of 
HCl  free,  is  rapidly  and  easily  evacuated  by  the  stomach, 
and,  when  given  fresh,  sweet,  and  sterile,  does  not  ferment  in 
the  ulcerated  stomach  free  from  stagnation  or  retention.  But 
unfortunately  an  exclusive  milk  diet  is  a  starvation  cure,  and 
is  only  capable  of  maintaining  the  balance  of  nutrition  of  the 
inactive  body  for  a  short  time,  when  given  in  the  quantity 
admissible  in  ulcer.  The  cure  should  always  be  begun  with 
absolute  rest  and  a  milk  diet;  but  the  development  of  inani- 
tion, which  constitutes  one  of  the  dangers  of  this  disease, 
should  be  most  stubbornly  fought. 

In  some  cases  the  stomach  is  intolerant,  or,  on  account  of 
a  hemorrhage  or  of  fresh  perforation,  must  be  given  complete 
functional  rest.  This  perfect  repose  may  be  secured  for  a 
short  time  by  rectal  feeding.  The  best  forms  of  nutrient 
enemata  are  given  in  the  section  on  General  Medication.  All 
the  water  and  a  little  of  the  nutriment  required  by  the  organ- 
ism may  be  introduced  in  this  way.  But  rectal  feeding  should 
also  be  employed  to  supplement  the  insufficient  milk  diet. 

The  quantity  of  milk  given  by  the  mouth  during  the 
twenty-four  hours  should  not  exceed  two  quarts,  and  should 
be  perfectly  sweet  and  unskimmed.  The  emulsionized  fat  is 
not  objectionable,  and  adds  to  the  nutritive  value  of  the  milk. 
For  the  first  day,  a  glass  may  be  slowly  sipped  every  three  or 
four  hours,  or  until  it  is  certain  that  the  milk  is  well  borne 
even  a  smaller  quantity  may  be  tried.  After  a  few  days  one 
glass  should  be  given  every  two  hours,  eight  glasses  being 
administered  during  the  twenty-four  hours.  No  more  than 
one  glass  of  milk  should  be  given  at  a  feeding,  and  the  inter- 
vals between  the  feedings  should  be  long  enough  to  allow  the 
stomach  to  become  empty.  It  is  a  good  plan  to  have  an 
interval  of  four  hours  after  the  fourth  glass,  so  as  to  avoid 
accumulation  and  distention  of  the  stomach.  This  leaves  an 
interval  of  eight  hours  between  the  last  evening  and  the  first 
morning  glass.  The  four  pints  of  milk  possess  a  nutritive 
value  of  about  1200  C,  and  are  not  quite  sufficient  to  main- 
tain the  balance  of  nutrition  while  the  patient  is  resting  in 
bed.  One  or  two  tablespoonsful  of  milk-sugar  may  be 
added  to  the  first  glass  of  milk  taken  in  the  morning — it 
is  both  a  food  and  a  laxative.  The  emaciation  which  soon 
begins  may  be  diminished  by  protecting  the  body  against 
loss  of  heat,  and  by  rectal  feeding. 


502  DISEASES  OF  THE  STOMACH. 

Tlie  exclusive  milk  diet  is  continued  until  four  or  five  days 
after  the  pain  and  vomiting  subside,  and  after  the  tender 
points  become  less  sensitive.  The  nutritive  value  of  the 
fluid  diet  should  then  be  increased  by  additions  to  the  milk. 
The  quantity  of  water  in  the  four  pints  of  milk  is  sufficient, 
and  should  not  be  increased.  Two  or  three  times  a  day  a 
small  quantity  of  a  thoroughly  cooked  preparation  of  wheat 
should  be  stirred  into  the  milk.  If  this  is  well  borne,  a 
few  days  later  instead  of  one  of  the  glasses  of  milk  a  cup  of 
meat  broth,  with  a  beaten  egg  slowly  stirred  in  while  the 
broth  is  not  hot  enough  to  coagulate  the  albumin,  may  be 
given.  Instead  of  the  egg,  two  tablespoonsful  of  freshly 
prepared  meat  powder  or  a  teaspoonful  of  "  Somatose  "  may 
be  used.  A  liquid  diet  of  this  sort  should  be  continued  until 
there  is  no  longer  any  digestive  discomfort,  the  changes  in 
the  diet  being  suggested  not  by  the  lapse  of  weeks  and  of  days, 
but  by  the  improvement  in  the  sN'niptoms  and  the  signs.  Ten- 
der meats  and  the  preparations  of  cereals  and  fresh  butter 
should  be  gradually  added,  and  the  patient  should  be  held 
for  several  months  on  a  mixed,  non-irritating  diet.  The  chief 
components  of  this  diet  are  milk,  eggs,  cereals,  butter,  and  the 
tender  meats.  Later  may  be  added  vegetables,  in  the  form 
of  purees;  but  acid  fruits,  alcoholic  drinks,  rich  foods,  con- 
diments, and  sweets  must  long  be  avoided. 

The  diet  is  sufficient  to  nourish  the  body,  provided  repose 
is  at  the  same  time  enforced  and  the  intestines  are  healthy, 
and  the  work  of  the  stomach  is  greatly  reduced. 

Two  other  conditions  demand  attention  and  may  be  treated 
by  the  same  remedies — the  hydrochloric  superacidity  and 
constipation  or  diarrhea.  The  inanition,  the  hemorrhagic 
anemia,  and  the  favor  shown  the  stomach  tend  to  correct 
the  hyperchlorhydria,  the  best  remedy  for  which,  if  it  be  a 
reflex  sign  of  the  ulcer  itself,  is  to  keep  the  stomach  empty 
for  twenty-four  hours;  but  the  hydrochloric  superacidity  is 
frequently  an  expression  of  an  associated  h\'persthenic  gastri- 
tis. No  remedies  are  then  so  beneficial  as  alkalies  in  large 
doses,  and  the  contents  of  the  stomach  should  be  kept  nearly 
neutral  by  their  free  administration.  The  three  most  useful 
alkalies  are  the  bicarbonate  of  soda,  calcined  magnesia,  and 
prepared  chalk,  and  these  may  be  advantageously  combined. 
From  two  to  four  drams  of  the  soda  should  be  given  during 
the  twenty-four  hours,  and  enough  magnesia  and  chalk  should 
be  combined  with  it  to  control  the  constipation  or  to  check  a 
temporary  diarrhea.     The  quantity  for  the  twenty-four  hours 


ULCER    OF   THE   STOMACH.  503 

should  be  divided  so  that  one  powder  is  given  at  the  end 
of  each  feeding.  This  neutraHzation  and  laxative  treatment 
contributes  to  the  relief  of  the  symptoms,  favors  cicatrization 
by  combining  the  free  HCl,  which  is  a  cause  of  the  chronicity 
of  ulcer,  promotes  the  early  and  easy  evacuation  of  the 
stomach,  and  does  not  lessen  the  utilization  of  the  milk. 
The  alkaline  cachexia  is  an  imaginary  danger,  and  the 
neutralization  method  should  be  employed  wherever  there  is 
hyperchlorhydria,  which  is  also,  in  a  degree,  controlled  by 
small  doses  of  the  extract  of  belladonna.  Instead  of  these 
alkalies  a  Carlsbad  cure  may  be  employed,  or  a  glass  of 
Celestins  vichy,  with  enough  sulphate  of  soda  to  regulate  the 
bowels,  may  be  given  every  morning. 

When  the  diet  is  digested  without  pain,  or  heartburn,  or 
eructations,  or  hyperchlorhydria,  all  drugs  should  be  kept  out 
of  the  stomach,  except  possibly  nitrate  of  silver  and  subni- 
trate  of  bismuth,  which  are  supposed  to  exert  a  favorable 
influence  on  the  cicatrization  of  the  ulcer. 

There  can  be  no  doubt  as  to  the  value  of  nitrate  of  silver. 
The  greatest  benefit  will  be  obtained  from  its  employment 
when  there  is  either  functional  or  inflammatory  hyperchlor- 
hydria, or  hyperesthesia  of  the  mucous  membrane.  It  often 
relieves  rapidly  the  pain  and  the  vomiting.  There  is  no  reason 
to  believe  that  it  exerts  a  direct  specific  action  on  the  ulcer, 
but  clinical  experience  proves  the  value  of  the  drug  in  all 
hypersthenic  states  of  secretion  which  are  not  due  to  the  stag- 
nation or  the  retention  of  irritant  contents.  One-fourth  to  one- 
half  of  a  grain  should  be  given  daily,  with  an  intermission 
after  two  weeks.  This  dose,  dissolved  in  a  tablespoon ful  of 
distilled  water,  should  be  given  every  morning  twenty  minutes 
before  the  first  feeding.  In  rebellious  cases,  with  no  history 
of  hemorrhage,  a  solution  of  nitrate  of  silver  (i  :  2000)  may 
be  used  to  douche  the  cleansed  stomach.  The  procedure 
may  be  repeated  every  three  days,  and  controls  the  excessive 
secretion  of  the  hypersthenic  gastritis  better  than  any  other 
remedy. 

The  bismuth  treatment  has  some  very  warm  advocates. 
The  pure  subnitrate  may  be  recommended  in  very  large 
doses.  The  indications  for  its  employment  are  the  same  as 
those  for  the  nitrate  of  silver;  but  it  is  of  less  value. 
One  or  even  two  drams  should  be  given  daily  in  a  single 
dose,  preferably  in  the  morning  half  an  hour  before  the  first 
feeding.  The  patient  should  lie  on  the  back  for  ten  minutes, 
and  then  on  the  right  side,  with  the  fond  hope  that  the  bis- 
muth may  fall  into  the  ulcer  as  a  protecting  deposit.     Small 


504  DISEASES  OF  THE  STOMACH. 

doses  do  no  good  ;  the  large  doses  may  not  constipate,  but 
should  not  be  given  for  a  long  period.  Fleiner  uses  the  bis- 
muth in  large  doses,  and  introduces  it  through  the  stomach- 
tube,  after  lavage  in  the  early  morning  before  breakfast.  Two 
to  three  drams  of  pure  subnitrate  of  bismuth  are  mixed 
with  a  glass  of  water,  and  the  mixture  is  allowed  to  flow  into 
the  stomach.  The  patient  then  occupies  various  positions — 
on  the  back,  on  the  right  and  left  sides,  upright,  and  in  the 
knee-elbow  position.  After  five  or  ten  minutes  the  water  is 
withdrawn  through  the  tube.  The  procedure  is  repeated  daily 
until  the  pain  disappears,  and  then  the  intervals  are  made 
longer.  Fleiner  has  used  from  ten  to  twenty  ounces  of  bis- 
muth before  interrupting  the  treatment,  without  producing 
symptoms  of  poisoning.  The  bismuth  forms  a  protecting 
coating  over  the  ulcer,  stimulates  granulation,  controls  the 
excessive  secretion,  and  Fleiner  claims  that  it  is  also  a  hemo- 
static. Bismuth  has  given  us  most  excellent  results,  without 
employing  lavage.  There  is  little  gained  by  withdrawing 
the  small  quantity  of  water  (only  a  small  part  of  the  bismuth 
is  recovered  after  ten  minutes),  and  it  would  seem  that  the 
stomach  is  already  clean,  or  may  be  sufficiently  cleansed  b}'  a 
glass  of  Carlsbad  water  administered  one  hour  before  the  bis- 
muth is  given.  We  ordinarily  give  a  daily  dose  of  one  or  two 
drams  for  a  week  or  ten  days  by  the  mouth,  suspended  in 
half  a  glass  of  water,  and  are  somewhat  timid  about  using 
the  tube. 

The  hemorrhage  of  ulcer  is  small  or  profuse.  The  most 
essential  part  of  its  treatment  is  absolute  rest  in  bed,  and  a 
continuously  empty  stomach.  No  food,  or  fluids,  or  ice,  or 
medicine  should  be  given  by  the  mouth.  The  administration 
of  tannin,  acetate  of  lead,  subsulphate  of  iron,  and  other 
locally  acting  hemostatics  is  irrational.  It  is  not  probable 
that  they  will  come  in  contact  with  the  part  on  which  they 
are  intended  to  act.  Worthless,  also,  is  ice,  being  virtually  the 
same  thing  as  the  administration  of  lukewarm  water,  and  the 
only  certain  effect  is  the  dilution  of  the  blood  and  the  pre- 
vention of  its  coagulation.  The  stomach,  when  it  is  still  and 
empty,  and  strongly  retracted,  is  in  a  most  unfavorable  con- 
dition for  the  continuance  of  the  hemorrhage.  As  a  last 
resort,  in  a  continuous  hemorrhage  lasting  for  several  days 
(very  rare  in  ulcer  but  more  frequent  in  carcinoma),  the 
stomach  may  be  washed  out  with  ice-cold  water  and  left 
empty. 

The  first  object  is  to  arrest  the  hemorrhage,  and  the  treat- 
ment is  different  when  the  hemorrhage  is  small  and  when  it  is 


ULCER    OF   THE   STOMACH.  505 

large.  Absolute  rest  and  mental  quietude  are  essential  con- 
ditions. These  being  secured,  an  ice-bag  is  kept  over  the 
stomach  to  cause  it  to  retract,  and  a  hypodermic  injection  of 
morphin  is  given  to  quiet  the  circulation  and  to  diminish 
peristalsis.  If  the  hemorrhage  continues,  ergot  should  be 
given  hypodermically.  This  drug  contracts  the  arteries  as 
large  as  the  radial,  and  strengthens  the  tonic  contraction  of 
the  stomach  ;  but  its  action  on  the  muscular  fiber  of  the 
stomach  is  feeble  in  comparison  with  its  action  on  that  of 
the  uterus.  Clinical  experience  demonstrates  the  value  of  the 
drug  in  checking  gastric  hemorrhage. 

If,  as  is  usual  in  ulcer,  the  hemorrhage  be  profuse,  and  the 
foregoing  remedies  are  not  effective,  ligatures  may  be  placed 
around  the  thighs  and  drawn  tight  enough  to  obstruct  the 
return  venous  but  not  the  outward  arterial  circulation. 
Enough  blood  may  thus  be  withdrawn  temporarily  from  the 
circulation  to  check  the  hemorrhage  and  to  give  time  for  the 
clot  to  form.  The  dammed-up  blood  should  be  allowed  to 
reenter  the  general  circulation  slowly. 

The  hemorrhage  being  arrested,  collapse  may  demand  im- 
mediate treatment.  The  head  and  the  body  being  placed  on 
a  level,  the  extremities  should  be  raised  and  the  blood  mas- 
saged out,  and  compressing  bandages  should  be  applied.  A 
pint  of  a  warm  physiological  solution  of  common  salt  (0.6 
per  cent.)  should  be  introduced  into  the  rectum  and  its  escape 
prevented.  Another  pint  of  the  same  solution  should  be 
injected  into  the  subcutaneous  cellular  tissue,  the  points  of 
election  being  the  lower  angle  of  the  scapula  and  the  outer 
part  of  the  thigh. 

The  heart  should  be  aroused  by  hypodermics  of  camphor- 
ated oil  and  ether.  Transfusion  might  be  tried  to  prevent 
immediate  death,  in  case  the  necessary  apparatus  be  at  hand. 
For  three  or  four  days  after  the  ces.sation  of  the  hemorrhage 
rectal  feeding  should  be  used  exclusively.  A  little  milk 
may  then  be  given  cautiously  and  tentatively  by  the  mouth, 
and  gradually  oral  may  be  substituted  for  rectal  feeding. 

The  pain  is  nearly  always  relieved  by  the  appropriate  treat- 
ment of  the  ulcer.  Morphin  hypodermically,  or  the  extract 
of  opium  in  suppository,  may  be  required.  A  very  good 
pain-relieving  combination  is  that  of  codein,  extract  of  bella- 
donna, and  calcined  magnesia. 

Vomiting  may  be  an  obstinate  symptom,  and  if  not  relieved 
by  rest,  by  diet,  and  by  bismuth  or  nitrate  of  silver,  the  stom- 
ach should  be  given  complete  rest  for  from  twenty-four  to 
forty-eight  hours,  and  oral  feeding  should  be  resumed  under 


5o6  DISEASES  OF  THE  STOMACH. 

the  soothing  influence  of  the  Winternitz  compress.  Vomit- 
ing occurring  at  the  climax  of  the  painful  digestive  paroxysms 
is  prevented  b\'  controlling  the  pain. 

The  medical  treatment  of  perforation  should  be  begun  with- 
out delay,  the  object  being  to  localize  the  resulting  peritonitis. 
The  patient  should  be  kept  absolutely  still  in  bed,  and  a  full 
dose  of  morphin  should  be  given  hypodermically.  The 
morphin  must  be  repeated  in  full  doses  at  short  intervals,  so 
as  to  immobilize  the  digestive  tube.  By  rectal  administration 
it  is  difficult  to  keep  the  patient  mildly  and  continuously  nar- 
cotized. Ice-cold  applications  should  be  placed  over  the 
abdomen.  The  ice-bag  is  usually  too  heavy  to  be  borne. 
The  coil  of  rubber  tubing  with  a  continuous  flow  of  ice-water 
through  it  is  light  and  convenient.  Often  cold  is  not  bear- 
able, and  the  Winternitz  compress  should  be  substituted  for 
it.  Shock  following  perforation  may  demand  the  hypodermic 
employment  of  camphorated  oil,  ether,  and  strychnin.  Food 
and  water  during  the  first  four  or  five  days  should  be 
given  exclusively  by  rectum,  and  the  first  nutrient  enema 
should  not  be  administered  until  the  digestive  tube  has  virtu- 
ally been  put  in  splints  by  the  free  use  of  opium.  The  best 
and  most  rational  treatment  is  immediate  surgical  interven- 
tion. 

Local  peritonitis  before  perforation  should  be  treated  on  the 
same  principles,  as  it  may  be  either  purulent  or  plastic.  But 
the  treatment,  which  is  exclusively  medical,  is  much  less 
energetic.  Absolute  rest  in  bed,  cold  over  the  epigastrium, 
enough  opium  to  relieve  pain  and  to  quiet  peristalsis,  and 
exclusively  rectal  feeding  for  a  few  days  are  the  chief  points 
of  the  management.  The  stomach  should  be  given  complete 
rest  for  as  long  a  period  as  the  state  of  nutrition  will  permit. 

Painful  adhesions  give  a  good  deal  of  trouble,  and  nothing 
is  likely  to  prove  efficient  except  the  gentle  influence  of  time. 
Counterirritation  over  the  stomach  and  on  either  side  of  the 
dorsal  spine  may  be  tried,  and  prolonged  use  of  the  compress 
sometimes  gives  relief.  Precautions  should  be  taken  to  pre- 
vent the  formation  of  a  drug  habit  if  anodynes  are  prescribed. 
Many  of  the  complications  and  sequelae  can  not  be  treated  by 
operation.  Perforation  converts  ulcer  into  a  surgical  disease; 
abscess  must  also  be  treated  with  the  knife  ;  and  obstruction 
of  the  pylorus  or  of  the  cardia  may  require  an  appeal  to  the 
surgeon  for  relief. 

Some  Ulcer  Cures. —  I.  The  Rest  and  Carlsbad  Cure. — This 
ulcer  cure  is  very  popular  in  Germany,  and  has  been  carefully 
formulated  by  von  Ziemssen  and  Leube.     Von  Ziemssen  does 


ULCER    OF   THE   STOMACH.  507 

not  enforce  absolute  rest  in  bed,  but  forbids  physical  and 
mental  overexertion.  The  abdomen  is  protected  by  a  flannel 
bandage.  Milk,  tender  meats,  milk-  and  cereal-thickened 
soups,  and  white  bread  are  permitted.  In  combination  with 
this  regime  must  be  used  systematically  a  solution  of  artificial 
Carlsbad  salts  in  hot  water.  Two  to  four  drams  (one  to  two 
heaped  teaspoonfuls)  are  dissolved  in  a  pint  of  hot  water, 
and  the  whole  is  drunk  slowly  in  four  portions,  fifteen  minutes 
apart,  and  finished  half  an  hour  before  breakfast.  One  or  two 
stools  must  follow,  and,  according  to  the  effect  produced,  the 
quantity  of  salts  must  be  increased  or  diminished.  As  a  rule, 
one  heaped  teaspoonful  is  sufficient  after  a  day  or  two.  If 
the  hydrochloric  acidity  be  very  high,  a  glass  of  Giesshiibel, 
Bilin,  or  Vichy  may  be  given  at  night.  Three  or  four  weeks 
are  usually  required  to  cause  all  symptoms  to  cease  and  the 
ulcer  to  heal.  The  Carlsbad  salts  are  now  stopped,  but  the 
glass  of  mineral  water  is  continued  for  a  few  weeks.  Von 
Ziemssen  claims  that  the  cure  of  the  ulcer  is  due  to  the  salts 
and  to  the  large  quantity  of  hot  water.  The  highly  acid 
contents  are  neutralized,  the  acid  fermentation  is  checked,  the 
stagnation  is  relieved  by  complete  daily  evacuation  of  the 
stomach,  and  a  daily  movement  of  the  bowels  is  obtained. 
There  is  no  doubt  that  the  Carlsbad  cure,  methodically 
employed,  reduces  rapidly,  after  the  first  few  days,  the  hydro- 
chloric superacidity,  and  relieves  the  constipation.  But  in 
ulcer  there  is  neither  myasthenia,  nor  obstruction  with 
stagnation,  nor  retention  and  fermentation  ;  or,  if  these  com- 
plications be  present,  the  water  cure  is  strongly  contra- 
indicated.  Carlsbad  salts  should  not  be  used  if  there  be 
anemia. 

Leube  conducts  the  cure  with  the  patient  in  bed,  and  all 
movements  requiring  effort  are  forbidden.  Hot  compresses 
are  kept  over  the  stomach  during  the  day,  and  a  Priessnitz 
compress  at  night ;  or,  in  case  of  hemorrhage,  ice-cold  appli- 
cations are  substituted.  From  a  glass  to  a  glass  and  a  half  of 
Carlsbad  water  (Muhlbrunnen)  in  which  from  a  half  to  one 
tablespoonful  of  artificial  Carlsbad  salts  has  been  dissolved  is 
given  daily  one  hour  before  breakfast.  But  in  the  beginning 
the  diet  consists  of  the  Leube-Rosenthal  meat  solution,  either 
in  bouillon  or  in  milk — both  lukewarm.  After  two  or  three 
weeks,  pigeon,  chicken,  puree  of  potatoes,  thickened  soups,  and 
bread  are  permitted  for  another  week,  and  a  normal  diet  is 
gradually  resumed. 

2.  TJie  Rest  and  Rectal  Feedbig  Cure. — This  method  is  very 
efficient,  and,  among  others,  has  been  recommended  by  Wil- 


508  DISEASES  OF  THE  STOMACH. 

lianis  and  by  Donkin.  Tlie  patient  is  kept  quiet  in  bed,  and 
no  nourishment  is  given  by  mouth.  Every  three  hours  an 
enema  (one  ounce  of  beef  tea  and  two  ounces  of  milk,  or  three 
ounces  of  milk — Donkin)  is  given.  After  two  weeks  the  same 
food  is  given  by  mouth,  and  the  number  of  rectal  feedings  is 
gradually  diminished.  This  is  essentially  a  starvation  cure, 
and  in  many  cases  is  unnecessarily  severe,  and  the  inanition 
increases  the  dai\ger.  The  ulceration  may  progress,  and  a 
hemorrhage  in  this  condition  of  emaciation  and  weakness 
may  be  a  very  serious  menace  to  life.  The  composition  of 
the  best  rectal  nutritive  enemata  are  given  in  the  section  on 
General  Medication.  We  often  employ  exclusive  rectal  feed- 
ing for  a  few  days  (seldom  longer  than  a  week)  when  the 
hyperchlorhydria  and  pain  are  obstinate,  when  the  motor 
function  is  impaired,  when  a  hemorrhage  has  occurred,  and 
when  perigastritis  is  present.  The  functional  rest  and  the 
retraction  of  the  empty  stomach  both  promote  healing. 

3.  T/ie  Milk  and  Neutralization  Method  of  Debove. — Debove 
employs  an  exclusive  milk  diet  and  alkalies  in  sufficient 
quantity  completely  to  neutralize  all  the  hydrochloric  acid 
secreted.  The  milk  may  be  given  in  small  quantity,  repeat- 
edly, or  in  large  quantity  three  times  a  day.  Two  to  two 
and  one-half  liters  daily  are  sufficient  to  maintain  the  balance 
of  nutrition,  and  this  quantity  should  not  be  exceeded.  A 
glass  of  pure  undiluted  milk  is  given  every  two  hours  during 
the  sixteen  hours  while  the  patient  is  awake.  A  powder  or 
cachet  consisting  of  ten  grains  of  bicarbonate  of  soda  and 
three  grains  of  prepared  chalk  is  given  every  hour  between 
getting  up  and  going  to  bed,  and  a  dose  should  be  given  at 
night  if  the  patient  should  awake  with  pain.  Or  three  glasses 
of  milk  may  be  given  three  times  a  day.  During  the  three 
hours  succeeding  each  meal  the  alkaline  powder  is  given  every 
half  hour,  and  every  hour  during  the  remainder  of  the  day. 

Under  the  influence  of  this  treatment  the  pain  and  the 
vomiting  rapidly  cease.  The  Debove  meat  powder,  after  a 
week  or  two,  is  added  to  the  alimentation,  giving  at  first  one 
ounce  a  day.  A  little  later  cereal  powders  prepared  in  the 
same  way  may  be  used. 

When  the  pain  and  vomiting  have  been  absent  several 
weeks,  the  alimentation  is  increased  by  following  the  table  of 
digestibility  arranged  by  Leube,  and  15  grains  of  bicarbonate 
of  soda,  and  the  equivalent  of  three  grains  each  of  prepared 
chalk  and  calcined  magnesia,  according  to  the  state  of  the 
bowels,  are  given  every  half  hour  during  the  three  hours 
follovvinjr  the  three  meals. 


ULCER    OF   THE   STOMACH.  509 

This  method  is  rational,  and  is  sometimes  very  effective, 
even  where  severe  hypersthenic  gastritis  coexists  ;  but  the 
complete  neutralization  of  gastric  acidity  is  unnecessary  for 
so  long  a  period  in  the  majority  of  cases.  In  practice  it  is  an 
excellent  routine  method,  but  the  routine  treatment  of  any 
disease  of  the  stomach  is  not  commendable.  The  remedies 
should  be  selected  which  in  the  particular  case  best  fulfil  the 
indications. 

Surgical  Treatment. — In  certain  emergencies  the  advisabil- 
ity of  an  operation  must  be  considered.  An  appeal  to  surgery 
may  be  made  on  account  of  the  gravity  and  the  uncontrol- 
lable evolution  of  the  ulcer,  on  account  of  a  complication, 
or  on  account  of  a  resulting  deformity. 

Ulcer  may  be  grave  on  account  of  the  severity  of  one  or 
more  of  its  cardinal  symptoms — viz.,  pain,  hemorrhage,  or 
vomiting.  It  can  seldom  happen  that  either  pain  or  obstinate 
vomiting  should  demand  surgical  intervention,  but  an  opera- 
tion should  be  considered  a  means  of  possible  relief,  and  a 
justifiable  procedure  when  the  pain  and  vomiting  are  accom- 
panied by  progressive  emaciation  and  loss  of  strength  and 
by  intolerance  of  rectal  feeding.  Repeated  hemorrhages 
or  a  very  large  hemorrhage  may  be  treated  by  operation, 
the  bleeding  vessel  being  ligated  or  cauterized  ;  or,  if  the  loca- 
tion of  the  ulcer  is  favorable,  excision  may  be  better  practice  ; 
or  gastro-enterostomy  may  be  performed  after  the  arrest  of  the 
hemorrhage.  The  best  surgical  treatment  is  made  clear  only 
after  the  stomach  has  been  exposed  to  view,  provided  the 
strength  of  the  patient  will  permit  the  surgeon  to  carry  out 
the  best  plan. 

An  ulcer  may  be  grave  on  account  of  its  prolonged  course 
and  resistance  to  medication  or  on  account  of  its  location. 
An  ulcer  located  on  the  anterior  surface  and  accompanied  by 
local  plastic  peritonitis  should  be  treated  by  excision  and 
closure,  or  possibly  by  attachment  of  the  stomach  with  sutures 
to  the  anterior  abdominal  wall — as  a  prophylactic  measure 
against  perforation  into  the  general  peritoneal  cavity.  If  the 
ulcer  is  unhealed  (hemorrhages)  and  is  obstructing  the 
pylorus,  it  might  be  well  to  perform  pyloroplasty  or  gastro- 
enterostomy. When  ulcer  is  chronic  and  obstinate,  and  is 
accompanied  by  hypersthenic  gastritis,  gastro-enterostomy 
secures  rapid  evacuation  of  the  stomach  and  the  control  of 
the  excessive  secretion — two  conditions  which  are  very  favor- 
able to  the  healing  of  the  ulcer  and  to  the  cure  of  the 
gastritis.     Doyen  reports  21  successive  gastro-enterostomies 


5IO  DISEASES  OF  THE  STOMACH. 

without  a  death,  but  tlie  mortality  is  50  per  cent,  in  BiUroth's 
cHnic.  Conite  reports  1  death  in  12  gastro-enterostomies 
for  ulcer,  and  6  deaths  in  17  cases  in  which  the  excision  or 
resection  of  the  ulcer  was  done.     (Collected  cases.) 

Perforation  converts  ulcer  into  a  surgical  disease.  Perfora- 
tion may  produce  a  fistula,  or  an  abscess  in  an  attached 
(adhesions)  organ,  or  a  subphrenic  abscess,  or  general 
peritonitis.  An  abscess  imperatively  demands  the  use  of  the 
knife.  In  34  reported  cases,  15  recoveries  have  been  obtained 
by  operation  (Maydl,  Comte,  Beck,  Abbe,  Weir,  McCosh) ; 
but  without  an  operation  recovery  is  an  accident.  When  the 
ulcer  is  situated  on  the  posterior  wall  or  on  the  lesser  curva- 
ture, an  abscess  is  the  usual  result  of  perforation  ;  but  when 
the  ulcer  is  situated  on  the  anterior  wall  perforation  occurs, 
as  a  rule,  into  the  general  peritoneal  cavity.  While  recoveries 
have  been  reported  from  perforating  ulcer  without  operation 
(the  stomach  probably  containing  no  food  at  the  time  of  the 
perforation),  yet  it  may  be  laid  down  as  a  rule  of  conservative 
practice  to  operate  whenever  perforation  has  occurred  into 
the  peritoneal  cavity.  The  operation  should  be  done  as  early 
as  possible  ;  the  perforation  should  be  closed  by  suture,  either 
from  without  or  from  within  the  stomach  (after  or  without 
excision  of  the  ulcer);  the  peritoneal  cavity  should  be  thor- 
oughly washed  out  and  purulent  exudate  removed,  and  after- 
drainage  should  be  invariably  employed.  Pariser  has  collected 
43  operations  for  perforating  ulcer  with  1 1  recoveries.  Conite 
increases  the  number  to  65  operations  and  19  recoveries,  and 
Weir  and  Foote  more  recently  reported  23  recoveries  in  'j'i 
collected  operations.     The  following  is  their  interesting  table  : 

Time  ok  Operation.  Rkcovi-;rv.  Death.  Mortality. 

Under  twelve  hours     .    .  I4  9  39  per  cent. 

Twelve    to    twenty-four 

hours 4  l.>  76    "     " 

Over  twenty-four  hours  .  4  28  87    "     " 

Not  stated I  5 

Total 23  55  71  per  cent. 

The  conclusion  might  be  drawn  from  these  statistics  that 
surgery  rescues  about  29  per  cent,  of  these  patients  from 
death  ;  but  the  statistics  are  based  on  reports  and  not  on 
practice.  The  truth,  were  it  known  completely,  might  greatly 
alter  the  percentage.  But  we  think  that  it  is  a  good  rule  of 
practice,  for  the  guidance  of  physicians,  to  arrange  for  an 
operation  by  an  experienced  surgeon  as  early  as  possible  after 
the  occurrence  of  perforation. 


THE  NEOPLASMS   OF   THE   STOMACH.  51I 

Subphrenic  abscess  is  a  complication  which  imperatively 
demands  incision  and  drainage.  Without  operation  this 
complication  is  invariably  fatal.  Of  ten  cases  operated  by 
free  incision  and  drainage,  three  (Scheurlen,  Debove,  Rendu) 
recovered. 

Ulcer  may  leave,  as  a  sequel,  gastric  fistula,  cardiac  or 
pyloric  obstruction,  or  a  deformity  producing  retention. 
Gastro-enterostomy  is  the  proper  treatment  of  the  latter  con- 
dition, or  adhesions  should  be  broken,  and  multiple  pouches, 
vi^hich  have  resulted  from  constrictions,  should  be  connected. 
Gastric  external  fistula  should  be  laid  open  down  to  the 
points  where  it  perforates  the  parietal  peritoneum,  and  packed 
so  as  to  favor  healing  from  the  bottom.  The  treatment  of 
obstruction  of  the  orifices  is  discussed  in  another  chapter. 


CHAPTER   ill. 

THE  NEOPLASMS  OF  THE  STOMACH. 

The  neoplasms  of  the  stomach  are  malignant  or  benign. 
The  benign  tumors  are  very  rare,  and,  being  curiosities  of 
the  dead-house,  they  are  of  very  little  interest  to  the  physi- 
cian. Lipoma  of  the  stomach  is  usually  multiple,  is  either 
submucous  or  subserous  in  origin,  and  consequently  may 
form  prominences  on  either  the  mucous  or  the  peritoneal 
surfaces.  These  encapsulated  and  sometimes  lobulated  new 
growths  are  ordinarily  about  the  size  of  a  pea  or  nut,  and 
produce  no  alteration  of  the  mucosa  or  of  the  peritoneum, 
except  the  slight  nutritive  changes  due  to  pressure.  Fibroma 
or  fibromyoma  may  develop  toward  the  peritoneum,  or 
toward  the  mucosa,  forming  a  polyp.  They  are  ordinarily 
about  the  size  of  a  cherry,  occur  most  frequently  in  old  age, 
and  are  most  commonly  located  on  the  anterior  wall  and  in 
the  pyloric  region,  and  may  consequently  produce  obstructive 
stagnation  or  retention.  Lymphadenoma  is  rare,  but  unlike 
lipoma  and  fibroma  it  may  ulcerate;  this  lymphatic  disease, 
be  it  neoplastic  or  diffuse,  is  always  associated  with  the  same 
affection  of  the  intestines;  sometimes  the  liver  and  spleen  are 
involved,  and  the  rapid  cachexia  is  accompanied  by  leukemia. 
Polyadenoma  is  a  benign  epithelial  neoplasm,  which  may 
accompany  chronic  proliferating  glandular  gastritis,  and 
which  may  undergo  cancerous  transformation. 


512  DISEASES  OF  THE  STOMACH. 

The  malignant  tumors  of  the  stomach  are  sarcoma  and  car- 
cinoma. Sarcoma  of  the  stomach  is  very  rare,  but  secondary 
sarcoma  of  tlie  stomach  occurs  more  frequently  than  does 
secondary  carcinoma.  Sarcoma  of  the  stomach  presents  the 
same  histological  characteristics  as  sarcoma  of  other  organs. 
We  have  been  able  to  find  only  43  cases  in  literature.  It  is  most 
frequent  between  the  ages  of  fifteen  and  thirty-five,  is  nearly 
twice  as  frequent  in  men  as  in  women,  and  it  may  suppurate, 
ulcerate,  produce  hemorrhage,  and  cause  perforation.  Its 
gastric  symptoms  and  its  functional  and  bacteriological  signs 
are  the  same  as  those  of  cancer.  There  is  oligocythemia, 
and  there  may  be  leukocytosis  (polynuclear)  as  in  cancer; 
but  lymphemia  is  more  frequent.  The  spleen  is  always 
enlarged,  metastases  are  frequent  and  may  be  accessible  to 
excision  and  the  microscopical  examination  of  a  specimen. 
Sarcoma  of  the  stomach,  when  it  is  diffuse,  may  convert 
the  stomach  into  a  stiff  viscus  and  the  pylorus  into  a  rigid 
canal,  producing  incontinence  instead  of  retention.  Both 
primary  and  secondary  intestinal  sarcomata  seldom  produce 
obstruction. 


CANCER  OF  THE  STOMACH. 

The  stomach  is  one  of  the  favorite  sites  of  primary  car- 
cinoma, which  is  a  malignant  disease,  progressive  in  its  evolu- 
tion, and  fatal  in  its  termination.  As  a  result  of  modern 
diagnostic  methods,  cancer  of  the  stomach  may  often  be 
surely  and  early  recognized,  and  a  more  favorable  opportunity 
is  thus  offered  for  radical  and  palliative  surgical  treatment. 
By  medical  treatment  also  life  may  be  prolonged  and  the 
suffering  alleviated.  On  account  of  its  frequency,  malig- 
nancy, and  the  great  importance  of  its  early  diagnosis,  both 
to  the  physician  and  to  the  patient,  the  disease  should  receive 
careful  and  minute  study. 

Frequency. — The  number  of  deaths  due  to  cancer  of  the 
stomach  varies  in  different  localities,  at  different  ages,  and  in 
the  two  se.ves. 

If  reports  are  to  be  trusted,  cancer  of  the  stomach  is  very 
rare  in  Turkey,  in  Egypt  (Griesinger),  and  in  parts  of  South 
America  (Heizmann).  It  is  much  more  frequent  in  Switz- 
erland, in  Normandy,  and  in  the  region  of  the  Black  Forest 
than  in  other  localities  of  Euroi^e  (Antenrieth,  Haberlin). 
In  Vienna  (Nedopil)  there  are  annually  four  deaths  from 
cancer  in  every  5000  inhabitants,  and  of  these  one   is  due  to 


THE   NEOPLASMS  OF   THE   STOMACH. 


513 


cancer  of  the  stomach  ;  and  the  mortality  percentage  due  to 
cancer  is  3.2  per  cent.,  and  to  cancer  of  the  stomach  0.8  per  cent. 

The  mortality  from  cancer  of  the  stomach  is  twice  as  great 
in  Switzerland  as  in  Vienna  and  Berlin,  one  person  in  every 
2500  dying  annually  of  it  (Haberlin). 

From  the  statistics  of  Bryant  (official),  extending  over  a 
period  of  ten  years  from  1 884-1 893,  we  obtain  the  following 
figures : 


City. 

Population. 

Average  Number 
OF  Deaths  An- 
nually. 

Average  Number  of 

Deaths  Annually 

FROM  Cancer. 

New  York,     .    .    . 
Philadelphia,     .    . 
Baltimore,      .    .    . 

Boston, 

San  Francisco,  .    . 
New  Orleans,    .    . 

1,628,151 
1,022,355 

437,613 
432,752 
313,000 
246,021 

39,943 

21,708 

9,120 

10,273 

5,979 
6,771 

865 

'487 
226 

304 
202 
152 

Total,     .... 

4,079,892 

93,794 

2,236 

In  these  large  cities  2.38  per  cent,  of  all  deaths  are  due  to 
cancer,  and  Haberlin  and  Bryant  have  shown  that  this  per- 
centage is  slowly  increasing  from  year  to  year.  For  New 
York  city  the  percentage  is  2.8  in  1896,  or  i  death  from 
cancer  to  1697  inhabitants.  The  average  yearly  death-rate 
from  cancer  in  the  six  cities  mentioned  is  i  to  1825 
inhabitants.  From  25  per  cent,  to  40  per  cent,  of  all  cancers 
are  primary  cancers  of  the  stomach.  Haberlin  gives  41.5 
per  cent. ;  d'Espine,  42.4  per  cent.,  and  Virchow,  35  per  cent. 
About  one  per  cent,  of  all  deaths  are  caused  by  cancer  of 
the  stomach. 

Cancer  of  the  stomach  is  a  rare  disease  before  the  thirtieth 
year.  In  11 50  autopsies  performed  on  old  men,  Greenfeld 
found  in  nine  per  cent,  that  death  was  due  to  cancer  of  the 
stomach.  Less  than  three  per  cent,  of  the  cases  occur  before 
the  thirtieth  year,  more  than  two-thirds  of  the  cases  between 
forty  and  seventy,  about  one-fourth  between  fifty  and  sixty, 
one-sixth  between  thirty  and  forty.  Nearly  one-half  of  the 
cases  occur  between  the  ages  of  forty  and  sixty.  Mathieu 
(1884)  collected  from  literature  32  cases  before  the  thirtieth 
year.  Wilkinson  and  Widerhofer  observed  congenital  cases. 
Cullingsworth  and  Kaulich  have  reported  cases  occurring 
in  infancy.  Cancer  of  the  stomach  is  almost  unknown 
before  the  fifteenth  year,  but  from  this  age  the  chances  of 
dying  from  it  increase  with  each  decad. 
33 


514  DISEASES  OF  THE  STOMACH. 

About  twice  as  many  cancers  occur  in  women  as  in  men, 
and  this  preponderance  is  chiefly  due  to  the  frequency  with 
wliich  primary  cancer  attacks  the  uterus  and  the  female 
breast.  A  compilation  of  statistics  from  many  sources  shows 
that  in  women  cancer  of  the  stomach  is  a  little  more  frequent 
than  cancer  of  the  uterus.  Cancer  occurring  in  man,  in 
from  40  to  50  per  cent,  of  the  cases  attacks  primarily  the 
stomach  ;  in  women  only  in  from  20  to  30  per  cent.  Brauti- 
gam  and  Haberlin  give  the  proportion  as  6  or  7  to  5  ;  Brinton 
gives  9V2  to  7;  and  Fox,  Zy^  to  8.  Louis,  Valleix,  and 
Lebert  claim  that  cancer  of  the  stomach  is  slightly  more 
frequent  in  women.  Statistics  may  be  produced  to  sup- 
port the  contention  in  favor  of  the  predominance  in  either 
sex,  and  the  generally  admitted  predominance  in  man  is  so 
slight  as  to  be  of  little  moment  to  the  clinician. 

Etiology. — The  causation  of  cancer  is  unknown.  Riches, 
poverty,  season,  country,  city,  hard  mental  and  physical  work, 
and  inactivity  exert  no  perceptible  influence. 

Clinical  observation  claims  heredity  as  a  predisposing 
cause.  Remarkable  instances  of  the  persistence  of  the  dis- 
ease in  members  of  the  same  family  through  several  genera- 
tions are  on  record,  and  cancer  is  not  so  frequent  that  the  re- 
currences can  be  plausibly  explained  as  accidental.  But  the 
reference  to  inherited  influences  often  means  nothing  more 
than  a  confession  of  ignorance,  and  heredity  is  losing  more 
and  more  of  its  domain  each  day  as  knowledge  increases. 
Lebert  reported  that  seven  per  cent,  and  Haberlin  claims  that 
eight  per  cent,  of  the  cases  are  hereditary. 

Long-continued  and  repeated  irritation  is  always  stated  to 
be  a  predisposing  cause.  Some  show  of  reason  may  be  given 
this  contention  for  cancer  in  some  of  its  localizations,  but  on 
such  grounds  it  would  be  difficult  to  explain  the  genesis  of 
cancer  of  the  stomach.  A  stomach  constantly  irritated 
escapes  as  often  as  one  which  receives  better  treatment,  and 
one  of  the  characteristics  of  cancer  is  its  development  at  an 
advanced  age  in  a  stomach  which  has  previously  given  no 
signs  of  disease.  Cancer  is  a  disease  which  has  its  favorite 
sites,  and  develops  exclusively  in  certain  tissues,  some  of  which 
are  remarkably  well  protected  against  mechanical  and  chemi- 
cal irritation.  In  this  respect  it  acts  like  a  germ  disease.  A 
bacillus  has  been  reported  as  its  cause,  and  some  observers 
have  attributed  the  disease  to  sporozoa.  or  to  sporozoa-like 
bodies,  which  develop  in  the  epithelial  cells.  But  it  is  gener- 
ally admitted  that  the  so-called  sporozoa  are  degenerate  cells, 
or    represent    endocellular    changes  in    atypical    epithelium. 


THE  NEOPLASMS  OF  THE   STOMACH.  515 

Carcinoma  may  generally  be  conveyed  from  one  surface  to 
another  with  which  it  is  in  contact,  and  metastasis,  such  as 
occurs  in  pyemia  and  other  infections,  is  frequent.  But  the 
metastasis  of  carcinoma  seems  to  be  a  cellular  transplantation, 
for  the  secondary  neoplasms  consist  of  the  same  cell  as  the 
mother  neoplasm,  wheresoever  the  secondary  growths  appear. 
The  cancer  cell  grows  and  lives  like  a  parasite,  and  it  is  hardly 
possible  for  a  germ  to  cause  the  production  of  cells  of  a  par- 
ticjLilar  kind  in  organs  where  these  cells  do  not  exist.  That 
the  germ  of  cancer  grows  in  the  epithelial  cell  and  imparts  to 
it  a  malignant  reproductive  activity  is  an  admissible  h}'po- 
thesis. 

Pathological  Anatomy. — Anatomically,  cancer  of  the  stom- 
ach is  a  disseminating  new  growth,  consisting  of  a  stroma 
whose  interspaces  are  filled  with  cylindrical  or  atypical  epi- 
thelium. The  disease  is  essentially  a  malignant  epithelial 
invasion. 

The  growth  of  carcinoma,  beginning  at  a  single  point  in  the 
mucous  membrane,  is  best  studied  along  its  borders.  Pro- 
ceeding with  the  microscopic  study  of  the  cut  through  the 
zone  of  dissemination  toward  the  center  of  the  new  growth,  it 
will  first  be  noticed  that  the  epithelial  proliferation  is  confined 
within  the  glands  and  limited  by  a  basement  membrane.  The 
epithelium  next  pushes  out  budding  projections,  over  which 
the  basement  membrane  disappears,  and  leaves  the  epithelial 
cells  in  direct  contact  with  the  very  fine  and  newly-formed 
stroma,  which  is  usually  infiltrated  with  small  round-cells. 
These  projections  unite  across  the  tissues  separating  the 
glands,  and  extend  into  the  submucosa  and  the  deeper  layers, 
where  cancer  cells  collect  in  nests ;  or  the  neoplasm  develops 
in  lines  along  the  lymphatic  vessels,  and  the  bundles  of  con- 
nective tissue  and  of  muscular  fibers. 

In  the  formation  of  the  neoplasm  two  tissues  are  chiefly 
concerned.  The  periglandular  connective  tissue  is  infiltrated 
with  small  cells  and  cell  nuclei,  and  out  of  it  is  formed  the 
stroma  which  is  to  serve  as  a  framework.  Contemporane- 
ously with  the  development  of  new  connective  tissue  new 
blood-vessels  are  formed  (vascularization),  and  in  some  cases 
the  blood-vessels  are  very  numerous.  The  characteristic 
feature,  however,  is  the  unconfined  epithelial  proliferation. 
The  starting-point  may  be  the  epithelium  about  the  necks  of 
the  glands,  and  the  cancer  is  then  cylindrical-celled  ;  or  it  may 
be  the  epithelium  of  the  fundus,  when  the  epithelium  of  the 
new  growth  is  atypical.  The  new  cells  stain  intensely,  and 
typical  and  atypical  nuclear  growth  and  division  (karyokinesis) 


5l6  DISEASES  OE  THE  STOMACH. 

is  very  active.  The  ducts  of  some  of  the  glands  may  be 
lined  with  several  layers  of  cylindrical  epithelium.  The 
fundus  of  the  glands  is  usually  lined  with  one  layer  of  new 
ceils,  but  here  and  there  may  be  seen  two  or  more  layers,  and 
the  lumen  of  some  of  the  glands  may  disappear.  The 
epithelial  cells  invade  the  extraglandular  and  interglandular 
tissues,  and  form  here  and  there  nests  of  cells.  Accordingly 
as  the  stroma  or  the  epithelial  cells  predominate,  the  cancer  is 
hard  or  soft. 

Hard  cancer,  or  scirrhus,  is  the  most  common  anatomical 
variety  of  cancer  of  the  stomach.  According  to  Brinton,  it 
constitutes  72  per  cent,  of  the  cases.  Hard  cancer  begins 
almost  without  exception  in  the  pyloric  region,  and  infil- 
trates all  the  layers  of  the  gastric  wall  without  producing 
any  marked  prominences.  The  wall  of  the  stomach  is  hard 
and  thick,  inelastic,  and  non-retractile.  The  pylorus  is  often 
converted  into  a  rigid  and  incontinent  tube.  The  hard,  flat 
mass  may  be  located  chiefly  on  the  anterior  or  posterior  wall, 
or,  more  rarely,  may  convert  the  whole  stomach  into  a  hard, 
rigid  tube,  little  larger  than  the  cecum.  The  mucous  mem- 
brane in  the  area  of  the  tumor  is  often  ulcerated.  The  ulcer 
is  superficial,  with  very  low  receding  edges,  and  the  base  is 
smooth  and  scarlike  or  ragged  and  fibrous.  The  thickened, 
indurated  wall  cries  under  the  knife,  and  is  sometimes  white 
and  glistening,  with  but  little  milky  fluid  ;  and  is  sometimes 
yellow,  streaked,  or  spotted  with  hard,  white,  fibrous  tissue. 
All  the  layers  may  be  eventually  replaced  by  the  carcino- 
matous stroma,  with  only  here  and  there  a  few  epithelial  cells, 
not  resting  on  a  basement  membrane  and  arranged  along  the 
coarse  fibers  of  connective  tissue.  Scirrhus  may  be  con- 
founded with  chronic  ulcer  or  with  interstitial  gastritis.  The 
differentiation  may  be  made  by  comparing  the  evolution  ;  the 
extension  along  the  lymphatics ;  the  presence  of  epithelial 
cells  in  the  submucosa  and  muscular  layer,  unconfined  by  a 
basement  membrane ;  cancerous  nodules  in  the  peritoneal 
coat,  and  metastases  in  other  organs.  The  liard  cancer,  be- 
ginning almost  without  exception  in  the  pyloric  region, 
destroys  and  replaces  the  components  of  the  gastric  wall  by 
a  compact  connective-tissue  stroma  inclosing  a  few  epithelial 
or  giant  cells  and  cancer  nodules  and  very  sparingly  supplied 
with  blood-vessels.  Ultimately,  the  stomach  is  contracted, 
rigid,  and  functionless,  and  the  pylorus  is  obstructed  or  gajiing. 

There  are  two  varieties  of  soft  cancer — adenocarcinoma  and 
medullary  carcinoma.  The  first  variety  is  cylindrical-celled, 
and  grows  from  the  epithelium  lining  the  necks  of  the  glands 


THE   NEOPLASMS   OE   THE   STOMACH.  517 

and  covering  the  surface  of  the  mucous  membrane.  The 
epithelial  cells  constituting  medullary  carcinoma  are  small, 
irregular,  atypical,  embryonic,  and  resemble  the  chief  cells  of 
the  gastric  glands. 

Adenocarcinoma  is  a  fungoid,  vascular,  malignant  neoplasm 
morphologically  characterized  by  a  delicate,  infiltrated,  fibrous 
framework  inclosing  cylindrical  cells  so  arranged  as  to  form 
irregular  tubules.  The  favorite  location  is  the  pyloric  region 
and  the  pyloric  ring,  originating  in  the  epithelium  lining  the 
pyloric  glands,  and,  rarely,  also  in  the  cells  lining  the  excre- 
tory ducts  of  the  glands  of  other  regions  of  the  stomach. 
The  tumor  presents  a  soft,  fungous,  red  mass,  studded  with 
papillae.  The  blood-vessels  are  numerous  and  often  become 
irregular  in  caliber,  degenerated,  and  obstructed.  Subse- 
quently, the  growth  of  the  neoplasm  is  accompanied  by  inter- 
stitial hemorrhages,  necrosis,  ulceration,  and  small  hemor- 
rhages into  the  cavity  of  the  stomach.  On  section,  cancerous 
juice  exudes,  and  the  soft  surface  consists  almost  exclusively 
of  epithelium.  The  tumor  grows  along  the  surface  and  ex- 
tends very  slowly  to  the  deeper  layers.  A  microscopic  cut 
through  the  zone  of  invasion  reveals  irregular  cavities  lined 
by  cylindrical  epithelium  resting  directly  on  a  framework  of 
connective  tissue  infiltrated  with  small  round-cells.  Some- 
times the  cavity  is  filled  with  epithelium  atypical  in  form  and 
degenerated,  the  appearance  being  ultimately  very  much  like 
that  of  medullary  carcinoma.  The  glandular  arrangement, 
seen  under  the  microscope,  may  suggest  simple  adenoma. 
But  the  malignant  growth  forms  a  tumor  consisting  chiefly 
of  cylindrical  epithelium  without  a  basement  membrane,  and 
invading  the  layer  of  the  gastric  wall  beneath  the  mucous 
membrane.  The  formation  of  cancerous  nodes  and  the 
occurrence  of  metastasis  are  also  met  with  in  this  variety  of 
malignant  disease. 

Medullary  carcinoma  is  a  papillomatous  malignant  neo- 
plasm, often  ulcerated,  consisting  largely  of  small  atypical  epi- 
thelial cells.  It  grows  with  great  rapidity  and  invades  exten- 
sively the  glandular  system.  Like  all  the  anatomical  diseases 
of  the  stomach,  it  is  more  frequent  in  the  pyloric  end,  but 
occurs  in  other  parts  of  the  stomach  with  much  greater  fre- 
quency than  does  adenocarcinoma.  At  the  autopsy  it  most 
often  presents  an  ulcerating  tumor,  with  edges  exceedingly 
irregular  in  height  and  thickness,  occasionally  here  and  there 
smooth,  but  more  often  rugged,  with  a  base  varying  in 
appearance  accordingly  as  it  is  formed  by  the  submucosa  or 
by  the  muscular  or    peritoneal  coat.     A   section  of  the  wall 


5  1 8  DISEASES  OF  THE  STOMACH. 

usually  reveals  fatty  degeneration,  hemorrhages,  and  necrosis. 
The  epigastric,  portal,  celiac,  retroperitoneal,  inguinal,  and 
left  supraclavicular  glands  are  usually  enlarged,  and  cancerous 
nodules  and  cells  are  strung  along  tlie  lymphatics  in  the  gas- 
tric wall.  Microscopically,  the  epithelial  invasion  is  wide- 
spread, extending  in  the  wall  of  the  stomach  and  involving 
all  its  coats.  The  embryonic  chief-like  cells  are  often  found 
within  the  bundles  of  muscular  fibers  and  collected  in  spindle- 
shaped  nests  between  them. 

Either  form  of  soft  cancer  may  undergo  colloid  metamor- 
phosis, and  produce  what  is  often  described  as  a  distinct 
variety.  Medullary  cancer  undergoes  this  gelatinous  trans- 
formation or  degeneration  more  frequently  than  does  adeno- 
carcinoma. At  the  autopsy  a  tumor  appears;  commonly  as 
a  general  thickening  of  the  gastric  wall,  the  inner  surface 
presenting  ulcerated,  somewhat  transparent  prominences 
studded  with  small,  slimy  granulations.  The  outer  or  peri- 
toneal surface  is  nodulated.  Microscopically,  the  neoplasm 
consists  of  a  grayish,  fibrous  framework,  with  the  irregular 
interspaces  filled  with  gelatinous  matter  and  with  the  gran- 
ular remains  of  epithelial  cells.  From  the  invasion  zone  may 
be  obtained  cuts  presenting  the  microscopic  characteristics  of 
the  two  varieties  of  soft  cancer. 

The  mucous  membrane  lining  the  stomach  which  is  free 
from  the  cancerous  growth  always  presents  microscopic 
lesions  of  an  inflammatory  and  degenerative  character. 
The  histological  changes  are  most  commonly  those  found 
in  catarrhal  and  interstitial  and  atrophic  gastritis,  and  are 
most  probably  due  in  part  to  stagnation  of  the  contents 
and  to  the  influence  of  the  malignant  neoplasm  on  nutrition. 
The  relation  of  the  gastritis  to  the  cancer  is  not  known.  In 
some  cases  the  gastritis  undoubtedly  precedes  the  carcinoma, 
just  as  carcinoma  may  begin  in  the  edges  of  an  ulcer  of  the 
stomach,  or  it  may  be  preceded  by  hypersthenic  gastritis. 
It  is  possible  that  these  diseases  form  favorable  soils  for 
cancer.  But  the  gastric  mucosa,  as  a  rule,  undergoes  the 
same  pathological  alterations  when  cancer  affects  another 
organ,  such  as  the  breast.  The  microscopic  changes  are 
those  which  have  been  already  minutely  described  under 
chronic  catarrhal  gastritis,  accompanied  by  more  or  less  inter- 
stitial inflammation  and  degeneration  or  transformation  of 
the  peptic  glands.  The  cylindrical  surface  epithelium  is 
ordinarily  preserved,  but  it  may  be  lost  when  the  mucous 
division  of  the  mucosa  is  greatly  infiltrated  by  small  round- 
cells  and  leukocytes.     Many  of  the   cylindrical  cells  of  the 


THE   NEOPLASMS   OF   THE   STOMACH.  5  I9 

surface  and  of  the  ducts  (mouths)  of  the  glands  are  con- 
verted into  beaker  cells  and  ciliated  columnar  epithelium. 
The  border  cells  of  the  peptic  glands  disappear,  and  the  chief 
cells  are  replaced  by  the  cylindrical  epithelium  which  lines 
the  mouths  of  the  glands.  The  peptic  glands  are  thus  trans- 
formed into  mucous  glands  ;  or  the  fundus  of  the  peptic  gland 
may  be  destroyed  by  degeneration  and  interstitial  gastritis, 
and  the  cylinder-cell  lined  ducts  elongate  and  enlarge,  and 
may  eventually  extend  to  the  depth  of  the  submucosa. 
Wandering  leukocytes  and  eosinophile  corpuscles  lie  scattered 
among  the  infiltrating  round  cells.  The  motor  insufficiency 
results  from  the  cancerous  infiltration  of  the  muscular  layer 
in  the  region  of  the  neoplasm  or  is  due  to  pyloric  obstruc- 
tion. In  the  latter  case  the  muscular  coat  may  become 
hypertrophied.  In  no  other  anatomical  disease  of  the 
stomach  is  the  muscular  coat  so  early,  profoundly,  and  gen- 
erally affected.  Consequently,  motor  insufficiency  is  an 
almost  constant  sign  of  carcinoma.  The  alterations  of  the 
mucous  and  muscular  coats  produce  corresponding  and  char- 
acteristic functional  and  bacteriological  abnormalities. 

In  the  majority  of  the  cases  of  carcinoma  of  the  stomach 
adhesions  to  adjacent  organs  occur  before  death.  Exception- 
ally, when  the  disease  is  already  advanced,  the  stomach  re- 
mains free  from  adhesions,  and  the  tumor  may  be  moved 
about  in  the  abdominal  cavity.  The  absence  of  adhesions  is 
most  frequent  in  the  cylinder-celled  variety.  Unfortunately, 
adhesions  are  often  extensive,  and  constitute  a  serious  obstacle 
to  operative  interference,  forming  between  the  stomach  and 
the  liver,  pancreas,  colon,  diaphragm,  spleen,  omentum, 
abdominal  wall,  and  other  contiguous  parts. 

The  method  and  dissemination  of  carcinoma  is  strongly  in 
favor  of  the  parasitic  nature  of  the  epithelium  which  enters 
into  its  constitution.  The  neoplasm  may  spread  by  continuity, 
by  contact  or  inoculation,  or  by  the  lymphatics  and  veins. 
By  continuity  of  tissue  and  growth  the  neoplasm  extends  in 
the  wall  of  the  stomach  to  the  esophagus  and  duodenum,  and 
invades  adjacent  organs  over  the  bridges  made  by  adhesions. 
Detached  peritoneal  nodules  may  transplant  the  malignant 
growth  to  other  parts  of  the  peritoneal  cavity.  The  most 
common  method  of  propagation  is  along  the  lymphatics 
originating  in  the  primary  and  secondary  deposits.  The 
abdominal  lymphatic  glands  are  nearly  always  enlarged,  and, 
less  frequently,  the  inguinal  and  left  supraclavicular  glands. 
Cancer  may  also  be  disseminated  by  the  blood,  and  may  thus 
reach  the  liver,  and  from  this  organ,  or  directly  through  the 


520  DISEASES  OF  THE  STOMACH. 

thoracic  duct,  it  may  be  carried  to  the  lungs,  skin,  and  other 
distant  organs.  The  secondary  deposits  retain  the  morpho- 
logical characteristics  of  the  primary  carcinoma,  and  are  most 
frequent  in  the  liver,  where  they  exist  in  about  one-third  of 
the  cases.  The  size  of  the  metastatic  growth  is  in  no  constant 
relation  with  that  of  the  primary  carcinoma  of  the  stomach. 

Perforation  occurs,  on  an  average,  in  about  six  per  cent,  of 
the  cases.  The  statistics  of  various  authors  range  from  four 
to  ten  per  cent.  Perforation  is  the  result  of  ulceration  or  of 
gangrene,  and  opens  most  frequently  into  the  peritoneal 
cavity.  The  perigastritis  may  be  walled  in  and  purulent,  the 
subphrenic  abscess  usually  forming  in  the  right  hypochon- 
drium.  Perforation  may  also  occur  through  adhesions  into 
adjacent  solid  or  hollow  organs,  producing  an  abscess  or  a 
fistula.  A  fistulous  communication  of  this  kind  is  most  fre- 
quently established  with  the  transverse  colon,  and  sometimes 
externally  through  the  abdominal  wall. 

About  70  per  cent,  of  cancers  of  the  stomach  involve  one 
of  the  orifices,  and  30  per  cent,  are  diffuse  or  confined  to  the 
body  of  the  stomach.  It  is  commonly  reported  that  50  per 
cent,  to  60  per  cent,  of  cancers  are  pyloric.  But  the  situation 
of  the  tumor  at  the  autopsy  does  not  make  its  point  of  origin 
clear,  and  Israel  rightly  maintains  that  cancer,  as  a  rule,  does 
not  originate  in  the  orifices,  but  that  its  extension  is  arrested 
there.  In  40  cases  Boas  found  that  the  neoplasm  began  on 
the  lesser  curvature  twenty-five  times  and  si.x  times  on  the 
pylorus.  However,  as  revealed  by  autopsies,  the  neoplasm 
remains  confined  to  the  lesser  curvature  in  only  about  15  per 
cent,  of  the  cases. 

Clinical  Description. — Cancer  of  the  stomach  begins  insidi- 
ously with  tiie  SN-mptoms  of  chronic  asthenic  gastritis,  usu- 
ally after  the  thirtieth  year,  and  often  where  there  has  been 
no  digestive  trouble,  and  runs  its  course  rapidly  without  a 
stop,  and  is  accompanied  by  increasing  emaciation,  which  the 
most  careful  alimentation  is  unable  to  hold  in  check,  under 
favorable  circumstances,  for  more  than  a  few  months.  The 
appetite  is  early  lost,  but  exceptionally  it  remains  normal. 
The  symptoms  are  at  first  digestive,  but  encroach  more  and 
more  on  the  period  when  the  stomach  should  normally  be  at 
rest,  and  consist  of  a  sensation  of  heaviness  or  weight,  to  which 
are  soon  usually  added  pain,  nausea,  and  vomiting.  Indeed, 
two  clinical  groups  of  carcinoma  may  be  distinguished.  In  the 
one  group  pain  predominates,  and  is  accompanied  by  period- 
ical vomiting.  In  the  other  group  there  are  only  mild  symp- 
toms, such  as  digestive  discomfort,  heaviness,  flatulency,  and 


THE   NEOPLASMS   OF   THE   STOMACH.  52 1 

eructations  or  belching.  The  commencement  is  often  sudden, 
and  marks  the  end  of  a  long  period  of  good  digestion.  The 
course  may  be  characterized  by  remissions  and  short  periods 
of  improvement — little  breaks  in  a  cloud  that  never  lifts;  but 
death  usually  occurs,  from  self-poisoning  and  starvation,  in 
from  twelve  to  fifteen  months  after  the  first  clinical  manifesta- 
tions. In  some  cases  there  may  be  no  gastric  symptoms  for 
a  long  time,  the  disease  being  manifested  only  by  progressive 
emaciation  and  weakness.  But  these  latent  cases  are  infre- 
quent. The  clinical  picture  varies  accordingly  as  the  cancer 
involves  the  cardia,  the  body  of  the  stomach  only,  or  the 
pylorus. 

Carcinoma  beginning  on  and  limited  to  the  cardiac  orifice  is 
very  infrequent,  the  entrance  to  the  stomach  being  in  nearly 
every  case  involved  secondarily  by  extension  of  the  neoplasm 
from  the  adjacent  region  of  the  esophagus  or  stomach.  The 
trouble  begins  with  a  feeling  of  fullness  beneath  the  tip  of  the 
sternum,  usually  first  noticed  during  eating  or  soon  after  a 
bolus  of  solid  food  is  swallowed.  A  swallow  or  two  of  fluid 
relieves  the  sensation,  which  returns  from  meal  to  meal, 
and  daily  forces  itself  more  and  more  upon  the  attention. 
The  appetite  begins  to  fail,  and  the  feeling  of  fullness  and 
weight  becomes  more  obstinate.  The  patient  soon  learns 
that  fluids  pass  into  the  stomach  more  readily  than  solids, 
which  seem  to  stick  behind  the  sternum.  There  are  scarcely 
ever  sharp,  prolonged  attacks  of  lancinating  pain ;  indeed,  there 
is  seldom  any  severe  pain,  but  merely  at  times  a  little  dull, 
burning  sensation,  associated  with  the  consciousness  of  the 
presence  of  a  foreign  body  which  can  not  enter  the  stomach. 
Neither  swallowing  nor  external  pressure  with  the  hand  per- 
ceptibly increases  or  relieves  the  peculiar  discomfort.  Emacia- 
tion, which  began  with  the  first  symptom,  increases  more  rapidly 
as  the  food  is  restricted,  solids  being  excluded  as  a  result  of 
observation,  and  the  poor  appetite  further  cuts  off  the  quantity 
of  food.  But  the  emaciation  is  due  not  only  to  the  increas- 
ing cardiac  obstruction  and  to  the  self-imposed  fasting,  but  also 
to  the  increased  nitrogenous  waste  attributable  to  the  cancer 
itself.  As  the  obstruction  increases  food  collects  above  it  and 
dilates  the  esophagus.  The  fermentation  and  irritation  cause 
some  burning  pain  and  esophagitis.  Shooting  pains,  some- 
what severe  in  character,  which  have  no  connection  with  the 
meals,  are  sometimes  experienced.  The  food,  mixed  with 
mucus,  is  expressed  or  regurgitated  into  the  mouth,  and 
chemical  analysis  shows  that  it  has  not  entered  the  stomach. 


522  DISEASES  OF  THE  STOMACH. 

If  the  cancer  be  of  the  soft  variety,  a  marked  diminution  of 
the  obstruction  may  occur  by  ulceration,  and  false  hopes  may 
be  excited.  The  inanition  and  the  cancerous  intoxication, 
aided  sometimes  by  slow  hemorrhages,  bring  life  to  an  end  in 
from  six  to  ten  months  after  the  first  feeling  of  heaviness  was 
experienced. 

Carcinoma  of  the  body  of  the  stomach  begins  with  loss  of 
appetite,  with  digestive  trouble,  consisting  chiefly  of  a  sensa- 
tion of  heaviness  after  meals,  or  with  loss  of  strength  and  weight 
out  of  proportion  to  the  mild  local  gastric  disturbance.  There 
is  often  a  little  belching  of  gas  or  regurgitation  of  a  sour  and 
bitter  fluid.  Fats  and  meats  become  particular  objects  of  dis- 
gust. The  signs  of  fermentation  become  more  pronounced, 
and  pain  is  added  to  the  heaviness  which  encroaches  more 
and  more  on  the  period  of  normal  rest  of  the  stomach.  The 
pain  is  usually  dull,  little  influenced  by  the  taking  of  food  or 
by  vomiting,  occurs  during  the  period  of  normal  gastric  rest, 
and  may  persist  night  and  day.  The  pain  as  the  disease 
advances  may  change  in  character  and  become  at  times  lanci- 
nating, and  the  suffering  may  be  horrible.  The  food  is  often 
vomited,  without  producing  nausea,  as  a  rule,  but  sometimes 
with  a  good  deal  of  retching.  The  vomit  may  also  consist  of 
mucus  and  saliva,  and  is  likely,  particularly  if  there  is  exten- 
sive ulceration,  to  contain  altered  blood  and  to  be  a  dirty 
chocolate-brown  or  like  coffee  grounds.  The  patient  is  now 
pale,  haggard,  straw-colored,  cachectic.  Running  throughout 
the  evolution  of  the  disease  and  preserving  its  clinical  con- 
tinuity are  the  progressive  loss  of  strength  and  the  emacia- 
tion. After  twelve  to  fifteen,  or,  rarely,  eighteen,  months  the 
patient  dies,  a  helpless  skeleton.  Cancer  of  the  body  of  the 
stomach  may  be  latent,  and  throughout  the  course  of  the  dis- 
ease there  maybe  no  gastric  or  digestive  symptom  to  create 
a,  suspicion  of  the  location  and  nature  of  the  trouble.  The 
only  sign,  apart  from  those  furnished  by  the  functional  and 
bacteriological  examinations,  is  the  progressive  and  uncon- 
trollable emaciation. 

Cancer,  in  contrast  with  the  disease  involving  the  cardia, 
more  frequently  affects  primarily  the  pylorus.  Primary 
cancer  of  the  pylorus  rarely  extends  to  the  duodenum,  but 
may  spread  to  the  body  of  the  stomach.  Frequently  the 
pylorus  is  also  secondarily  involved  by  the  growth  of  the 
neoplasm,  beginning  on  the  body  of  the  stomach,  particularly 
the  lesser  curvature.     The  clinical  expression  is  modified  by 


THE   NEOPLASMS   OF   THE   STOMACH.  523 

the  affection  of  the  orifice,  and  the  signs  of  stagnation  or 
retention  appear  early  and  predominate.  In  cancer  of  the 
body  of  the  stomach  there  is  stagnation  and  retention,  but 
there  are  no  signs  of  pyloric  obstruction.  Where  the  disease 
involves  the  pylorus,  vomiting  is  more  frequent  and  copious, 
fermentation  more  active  and  mixed,  starvation  more  rapid, 
and  to  the  ordinary  loss  of  body  fat  and  the  excessive  nitro- 
genous waste  and  loss  of  strength  are  added  the  pernicious 
effects  of  insufficient  water  to  supply  the  needs  of  the  body. 
Thirst  is  often  annoying. 

Symptoms. — The  clinical  commencement  of  carcinoma  is 
commonly  sudden,  though  the  symptoms  in  the  beginning 
do  not  often  seem  to  be  serious.  The  middle-aged  patient 
sometimes  boasts  of  the  good  stomach  which  he  has  long  and 
uninterruptedly  enjoyed,  and  is  at  a  loss  to  explain  the  causation 
of  his  trouble.  But  it  should  not  be  imagined  that  a  disease 
of  the  stomach  is  a  protection  against  carcinoma.  Ulcer, 
indeed,  seems  to  furnish  within  narrow  limits  a  favorable 
opportunity  for  the  development  of  the  disease.  Traumatism, 
dietetic  excess,  or  some  trivial  cause,  occasionally  marks  the 
beginning  of  the  clinical  period. 

The  appetite  is  almost  invariably  poor.  It  is  better  pre- 
served when  the  cardia  is  affected  than  when  the  cancer  in- 
volves the  body  of  the  stomach  or  the  pylorus,  and  some- 
times remains  about  normal,  particularly  in  carcinomatous 
ulcer  and  in  cancer  in  the  early  period  of  life.  The  more 
active  and  varied  the  gastric  fermentation  and  intestinal 
putrefaction,  the  more  pronounced  is  the  anorexia.  There  is 
often  a  strong  disgust  for  meats  and  fats,  and  this  may  be  an 
early  symptom.  It  seems  that  the  dislike  for  fats  is  greatest 
when  butyric  acid  fermentation  exists.  The  disgust  for 
meats  is  absolute  when  the  contents  of  the  stomach  have  a 
putrefactive  odor,  and  the  instinctive  exclusion  of  meats  is  in 
keeping  with  the  loss  of  power  to  digest  them.  The  anorexia 
— which,  as  a  rule,  tends  to  become  complete — is  voluntarily 
resisted  by  the  patient,  and  is  in  vivid  contrast  with  the 
evident  needs  of  nutrition. 

A  sensation  of  heaviness  and  fullness  is  an  early  symptom 
of  carcinoma  which  is  almost  never  absent,  but  is  in  no 
respect  characteristic  of  the  disease.  Like  that  of  chronic 
gastritis  and  of  myasthenia,  it  appears  soon  after  taking  food. 
The  sensation  usually  persists  as  long  as  food  remains  in  the 
stomach,  and,  consequently,  increases  with  the  development 
of  stagnation  and  retention.  In  cancer  of  the  cardia  its  loca- 
tion is  beneath  the  lower  end  of  the  sternum,  but  sometimes 


524  DISEASES  OF  TJ/E  STOMACH. 

it  is  referred  lower  down.  When  the  neoplasm  is  situated  on 
the  body  of  the  stomach  or  involves  the  pylorus,  the  sensa- 
tion of  weight  and  fullness  may  extend  over  the  whole  area 
of  the  stomach,  and  is  often  most  distinct  at  the  lowest  point 
of  the  greater  curvature. 

Cancer  is  preeminently  a  painful  disease,  but  a  few  cases 
run  their  entire  course  without  pain.  These  exceptional 
painless  forms  are  more  frequent  in  old  age.  The  pain  of 
carcinoma  is  not  characteristic,  but  still  has  many  distinctive 
features.  It  is  sometimes  strictly  localized,  and  this  occurs 
most  frequently  when  the  pain  is  not  very  intense ;  but  more 
often  it  is  diffuse,  dull,  coming  in  exacerbations,  or  lancinat- 
ing, tearing,  and  radiating  into  the  back  or  beneath  the 
sternum.  It  does  not  depend  for  its  existence  on  the  taking 
of  food,  but  may  be  increased  b}'  irritating  food  or  by  food 
which  becomes  so  after  its  sojourn  in  the  stomach.  It  is  not 
perceptibly,  or  only  temporarily,  relieved  by  vomiting,  and  it 
does  not  cease  when  the  normal  period  of  gastric  digestion 
is  passed.  It  is  often  a  more  or  less  continuous  pain,  with 
e.xacerbations  occurring  independently  of  digestion  during 
the  day  and  during  the  night. 

There  is  no  very  close  and  constant  relation  between  the 
location  of  the  spontaneous  pain  and  the  situation  of  the 
neoplasm  ;  but  in  cancer  of  the  cardia  a  dull,  aching,  and 
sometimes  shooting  pain  is  frequent  in  and  about  the  left 
shoulder-blade.  The  coincidence  of  an  interscapular  pain 
with  the  location  of  the  neoplasm  on  the  lesser  curvature 
has  often  been  noticed.  The  pain  may  be  in  the  loins  when 
the  neoplasm  is  located  on  the  posterior  wall.  Epigastric 
and  dorsal  points  sometimes  exist  when  the  cancer  ulcerates. 
When  the  cancer  involves  the  pylorus,  the  pain  due  to  the 
malignant  growth  may  be  located  in  the  ejMgastrium  or  the 
left  or  right  hypochondrium,  but  the  pain  due  to  obstruction 
is  often  characteristic.  The  pain,  then,  often  appears  during 
the  period  of  digestion  in  paroxysms,  colicky  in  character, 
and  coinciding  often  with  gastric  peristalsis,  visible  on  the 
thin  abdominal  wall.  This  pain  of  obstruction  is  completely 
relieved  by  emptying  the  stomach  or  by  gastro-enterostomy. 

Vomiting  is  not  an  early  symptom  of  cancer  of  the 
stomach,  but  occurs  irregularly,  and  usually  three  or  four 
months  after  the  beginning  of  the  clinical  period.  When 
the  neoplasm  involves  the  cardia,  the  fluids  may  enter  the 
stomach,  and  the  little  regurgitant  vomiting  occurs  only 
during  or  immediately  after  a  meal  of  solid  food.  But  at  a 
more  advanced  period,  when  the  esophagus  is   dilated  above 


THE   NEOPLASMS   OF   THE   STOMACH.  525 

the  obstruction,  the  regurgitation  may  recur  much  later,  even 
during  the  period  of  rest  of  the  normal  stomach.  The  food 
is  for  a  time  retained  in  the  esophageal  sac.  As  the 
obstruction  becomes  more  complete  the  regurgitations  may 
consist  simply  of  swallowed  saliva  and  mucus.  Before  the 
fatal  termination  the  obstruction  is  sometimes  removed  by 
ulceration,  and  the  regurgitation  ceases ;  but  this  seldom 
occurs. 

A  few  cases  of  cancer  of  the  body  of  the  stomach,  par- 
ticularly when  well  treated,  run  their  course  without  vomit- 
ing. Vomiting  is  likely  to  be  infrequent  when  the  neoplasm  is 
located  on  the  posterior  wall,  or  when  it  is  of  the  hard  variety 
and  infiltrates  the  whole  body  of  the  stomach.  It  is,  however, 
often  uncontrollable,  and  produces  great  distress  when  the 
neoplasm  is  located  on  the  lesser  curvature.  The  vomiting 
is  most  frequent  after  taking  food  and  during  the  period  of 
digestion,  but  it  may  occur  when  the  stomach  should  be  empty, 
and  may  consist  of  the  mucus  and  saliva  swallowed,  or  par- 
ticles of  retained  food  may  be  brought  up  with  much 
retching. 

Vomiting  always  occurs  when  the  pylorus  is  involved,  and 
is  often  profuse  on  account  of  the  obstructive  retention.  In 
pyloric  cancer  the  vomiting  is  most  common  two  or  three 
hours  after  a  meal,  but  may  occur  at  any  moment. 

Hematemesis  is  observed  clinically  in  about  40  per  cent. 
(Brinton)  of  the  cases  of  carcinoma  of  the  stomach.  As  a 
rule,  the  hemorrhages  are  small  and  the  blood  passes  with 
the  gastric  contents  into  the  intestines,  or  it  appears  in  the 
vomit  after  having  undergone  partial  digestion  or  putrefaction 
in  the  stomach.  The  vomit  is  then  more  or  less  colored  by 
it,  and  is  often  like  coffee  grounds.  The  coffee-ground  vomit 
is  in  no  manner,  when  taken  alone,  characteristic  of  carci- 
noma, but  is  met  with  in  ulcer,  passive  congestion,  erosions, 
ulceration,  chronic  gastritis,  and  varicose  esophageal  veins. 
The  hemorrhage  of  cancer  is  seldom  sufficient  to  excite 
vomiting,  but  sometimes  a  large  vessel  (pyloric  artery)  is 
opened  and  a  profuse  and  fatal  hematemesis  results. 

Signs. — The  physical  signs  of  cancer  of  the  cardia  are  very 
important,  but  not  always  distinctive.  Percussion  and  pres- 
sure over  the  lower  end  of  the  sternum  are  often  painful,  and 
sometimes  exquisitely  so..  No  tumor  can  be  felt  or  seen.  The 
second  deglutition  sounds  are  sometimes  absent,  but  they  are 
more  often  delayed.  Rarely,  the  tumor,  by  pressure  on  the 
aorta,  produces  a  systolic  murmur,  and  makes  it  difficult  to  ex- 
clude the  existence  of  an  aneurysm,  which  should  always  be 


526  DISEASES  OF  THE  STOMACH. 

done  before  the  tube  is  used.  An  attempt  should  first  be  made 
to  pass  a  large  stomach-tube,  and  if  this  passes  readily  into  the 
stomach,  the  trouble  with  swallowing  which  has  prompted  the 
examination  is  most  likely  due  to  spasm  of  the  cardia.  But 
this  is  not  necessarlK'  the  case,  as  even  a  large  sound  sometimes 
passes  readily  in  the  early  stage  of  carcinoma  or  where  the 
cardiac  orifice  is  made  free  by  ulceration  of  the  neoplasm.  If 
such  be  the  case,  a  little  blood  and  mucus  will  probably  be  found 
in  the  eye  of  the  tube,  and  sometimes  nests  of  cancer  cells  or 
pieces  of  the  neoplasm.  If  the  stomach-tube  is  arrested,  and 
no  contents  of  the  dilated  pouch  can  be  aspirated,  a  little 
water  may  be  allowed  to  flow  in,  while  a  gentle  effort  is  made 
to  push  the  tube  further  on.  In  case  of  failure,  the  fluid 
should  be  aspirated  and  saved  for  examination,  and  the  tube 
withdrawn,  and  the  distance  to  the  obstruction  from  the 
incisor  teeth  should  be  measured.  An  effort  ma}'  be  made 
to  pass  soft  and  smaller  esophageal  sounds,  and  in  case  of 
failure,  and  no  evidence  of  the  nature  of  the  obstruction 
having  been  obtained,  the  examination  may  be  repeated 
after  the  administration  of  a  dram  of  bromid  of  potash  in 
two  or  three  doses.  If  the  obstruction  be  again  met  with, 
and  it  is  situated  about  40  cm.  from  the  incisor  teeth,  if  the 
patient  is  beyond  thirty  and  the  difficulty  has  been  steadily 
growing  since  its  commencement  a  few  months  previous 
with  loss  of  appetite  and  emaciation,  there  is  then  not  much 
doubt  that  there  is  a  malignant  growth  involving  the  cardiac 
orifice  of  the  stomach.  The  stomach  itself  is  abnormally 
small  and  retracted,  and  the  intestines  are  also  likely  to  be 
empty.  The  digestive  tube  becomes  more  and  more  con- 
tracted and  empty  as  the  obstruction  increases,  and  the  thin 
abdominal  wall  recedes  as  the  abdominal  contents  decrease. 
In  every  case  of  cancer  of  the  stomach  a  tumor  exists. 
Early  in  the  disease,  at  the  primary  site,  a  neoplastic  mass 
forms ;  and  later,  secondary  deposits  develop.  But  the 
primary  tumor  can  not  always  be  detected.  It  may  be  located 
on  a  part  inaccessible  to  physical  examination,  but  the  dis- 
placements of  the  stomach  which  so  frequently  exist  some- 
times remove  this  difficulty.  The  primary  growth  may  be 
covered  by  an  enlarged  liver  or  concealed  by  ascites.  The 
fullness  or  emptiness  of  the  stomach  ma)'  reveal  or  conceal 
the  tumor.  In  the  search  for  the  tumor  it  is  highly  impor- 
tant to  proceed  systematically.  The  examination  should  be 
made  when  both  the  stomach  and  bowels  are  empty.  Ascitic 
fluid  should  be  withdrawn.  The  examination  is  not  com- 
plete  until   it  has  also  been  made  while  the  stomach  is  dis- 


THE   NEOPLASMS   OF   THE   STOMACH.  $2^ 

tended  with  air  or  gas.  The  primary  growth  will  in  this 
way  be  more  likely  to  be  detected  and  properly  located.  If 
this  plan  be  adopted,  in  at  least  four-fifths  of  the  cases  of 
cancer  of  the  body  of  the  stomach  and  of  the  pylorus  a 
tumor  will  be  detected  at  some  time  during  their  evolution. 

A  palpable  tumor  is  not  an  early  sign  of  cancer  of  the 
stomach,  and  is  not  often  detected  before  the  beginning  of 
the  last  six  or  eight  months,  but  sometimes  earlier  and 
sometimes  nearer  the  end.  At  first  may  be  noticed  a  cir- 
cumscribed, resistant  area,  which  is  seldom  sensitive.  The 
tumor  grows  and  changes  its  character,  becoming  knotty, 
irregular  in  consistency,  larger,  adherent,  sometimes  exquis- 
itely tender,  but  more  frequently  manifesting  only  a  little 
more  pain  on  pressure  than  do  the  surrounding  parts.  The 
neoplasm  often  feels  harder  and  larger  on  palpation  than  it 
is  in  reality  after  allowance  is  made  for  the  surrounding 
inflammatory  swelling.  Even  the  soft  infiltrating  cancer 
produces  a  palpable  tumor. 

The  physical  signs  of  cancer  of  the  body  of  the  stomach 
may  be  of  the  greatest  diagnostic  value.  These  signs  con- 
sist almost  exclusively  of  the  physical  evidences  of  a  tumor 
possessing  the  particular  characters  of  a  malignant  growth. 
Cancer  of  the  posterior  wall  and  of  the  portions  of  the 
anterior  surface  and  the  greater  curvature  which  are 
covered  by  the  left  ribs  often  can  not  be  detected  by  physical 
examination.  Situated  on  other  parts  of  the  body  of  the 
stomach,  the  characteristic  tumor  may  often  be  found  ;  or  it 
is  first  found  when  these  parts  become  involved  by  extension. 

Cancer  of  the  lesser  curvature  may  lie  beneath  the  ribs 
and  the  left  lobe  of  the  liver,  and  be  inaccessible.  But  in 
the  large  majority  of  cases,  during  the  second  half  of  the 
clinical  period,  it  can  be  detected  if  the  stomach  be  empty, 
and  much  more  readily  if  the  stomach,  as  often  happens,  is 
displaced  downward  or  vertically.  On  inspection,  the  tumor, 
well  defined  above  and  below,  may  be  seen  moving  up  and 
down  on  inspiration  and  expiration,  emerging  from  be- 
neath the  costal  arch  toward  the  end  of  inspiration  and 
disappearing  from  view  as  the  diaphragm  rises.  On  palpa- 
tion, the  tumor,  visible  or  invisible,  can  often  be  felt,  and 
also  fixed  on  expiration,  unless  it  be  firmly  adherent  to  the 
diaphragm.  This  relation  of  the  tumor  to  the  movements  of 
the  diaphragm  is  a  very  important,  and,  when  taken  in  con- 
nection with  its  location  beneath  or  just  below  the  costal 
arch,  and  with  the  position  of  the  body  of  the  stomach  below 
it,  is  an  almost  characteristic  sign  of  a  tumor  of  the  lesser  cur- 


528  DISEASES  OF  THE  STOMACH. 

vature  of  the  stomach.  If  the  fingers  be  laid  flat  and  gently 
on  the  abdominal  wall,  the  tumor  glides  up  and  down  with 
expiration  and  inspiration  respectivel}'.  If  at  the  end  of  in- 
spiration the  tips  of  the  fingers  be  gently  but  firmly  pressed 
above  the  tumor,  the  mass  can  be  arrested,  and  when  released 
near  the  completion  of  expiration  it  slips  up  from  beneath  the 
fingers.  Another  important  characteristic  of  a  tumor  of  the 
lesser  curvature  is  its  inaccessibility  when  the  stomach  is  full. 
It  can  not  be  pushed  to  either  side. 

If  the  cancer  is  located  on  the  portion  of  the  greater  curva- 
ture uncovered  by  the  ribs,  the  tumor  is  situated  near  or 
beneath  the  umbilicus,  moves  with  respiration,  is  easily 
fixable  on  expiration,  and  is  most  accessible  when  the  stom- 
ach is  full.  The  tumor  is  sensitive,  commonly  knotty,  but 
is  sometimes  smooth,  and  usually  possesses  a  border  irreg- 
ular in  consistency  but  at  points  very  hard  and  sharply 
limited.  When  not  adherent  it  is  pretty  freely  movable  up 
and  down,  and  to  a  limited  extent  to  either  side. 

Cancer  of  the  accessible  part  of  the  anterior  wall  is  most 
easily  felt  when  the  stomach  is  moderately  distended  with 
gas,  the  artificial  distention  with  air  or  an  effervescent 
powder  being  far  preferable  to  distention  with  food.  The 
tumor  is  more  or  less  sensitive,  knotty,  and  here  and  there 
the  irregular  border  is  hard.  If  the  cancer  is  an  infiltrating 
scirrhus,  the  stomach  is  smooth,  small,  and  resistant.  The 
wall  is  non-elastic,  and  inflation  with  air  or  gas  produces 
severe  pain  without  increasing  the  size  of  the  stomach.  If 
the  tumor  is  situated  on  the  posterior  surface,  it  may  be  felt 
when  the  stomach  is  empty,  but  it  disappears  when  the 
stomach  is  full  or  distended.  Clinically,  what  is  sometimes 
felt  during  life  is  not  in  reality  the  primary  growth,  but 
secondary  deposits  in  the  omentum  or  in  the  left  lobe  of  the 
liver. 

In  cancer  of  the  body  of  the  stomach  the  organ  is  normal 
in  size  or  smaller  than  the  average.  If  it  be  enlarged,  the 
increase  in  size  is  an  accidental  association.  A  tumor  of  the 
body  of  the  stomach  sometimes  pulsates  on  account  of  being 
in  contact  with  the  abdominal  aorta.  The  pulsation  is  lifting, 
and  not  expansive  as  in  aneurysm.  If  the  tumor  be  free,  the 
pulsation  ceases  in  the  knee-chest  position,  and  when  the 
mass  is  pushed  to  either  side  so  as  not  to  come  in  contact 
with  the  aorta.  But  the  tumor  may  be  adherent,  surround 
or  compress  the  aorta,  and  produce  a  systolic  blowing  and 
whirring  murmur  and  diminution  of  the  arterial  pulse  below. 
The  differential  diagnosis  between  an  aneurysm  and  a  can- 


THE   NEOPLASMS   OF   THE   STOMACH.  529 

cerous  tumor  of  the  stomach  depends  in  such  a  case  on  the 
other  signs  or  symptoms  which  are  present  and  belong  only 
to  the  one  or  the  other  disease. 

The  tumor  of  pyloric  carcinoma  is  seen  or  felt  to  the 
right,  on,  or  sometimes  to  the  left  of,  the  median  line.  It  may 
be  invisible  and  inaccessible  to  palpation,  and  lie  deep 
beneath  the  liver.  But,  fortunately,  in  pyloric  cancer  the 
stomach  is  commonly  displaced,  and  its  palpation  is  made 
thereby  possible  and  easy.  The  tumor  moves  with  respira- 
tion, and  unless  adherent  is  fixable  on  expiration.  But  cases 
are  not  rare  where  the  pyloric  tumor  is  exceedingly  movable, 
and  may  be  pushed  about  in  the  right  iliac  fossa  (where  it  is 
sometimes  found)  and  across  the  median  line.  On  inflation 
of  the  stomach  the  tumor  of  the  pylorus  descends  to  the 
right  and  downward;  but  it  may  also  be  displaced  upward 
and  to  the  right,  or  simply  downward,  in  case  the  tumor  is 
bound  by  adhesions.  The  stomach  is  not  always  increased 
in  size  in  cancer  of  the  pylorus,  even  when  obstructive 
retention  exists,  and  peristalsis  may  be  strong  and  visible. 
When  the  cancer  converts  the  pylorus  (by  ulceration  or  by 
infiltration)  into  a  rigid  and  incontinent  ring,  the  air  may  be 
heard  rushing  through  the  pylorus  with  each  compression  of 
the  inflating  bulb. 

Naturally,  a  gastric  tumor  is  not  a  pathognomonic  sign  of 
cancer,  but  gathers  a  good  deal  of  its  value  from  the  asso- 
ciated symptoms  and  signs.  It  aids  in  the  location  of  the 
disease  and  in  the  selection  of  the  proper  treatment. 

The  emaciation  is  not  characteristic,  and  may  be  no  greater 
than  in  other  diseases.  But  the  skin  does  not  preserve  its 
clear  and  rosy  color,  as  in  the  extreme  emaciation  of  some 
nervous  affections  ;  nor  is  all  the  fat  lost,  as  in  simple  chronic 
inanition.  The  body  albumin  early  and  progressively  dis- 
appears, and  the  emaciation  and  cachexia  differ  from  the 
pale,  edematous  appearance  of  chronic  nephritis.  The  ema- 
ciation of  carcinoma  resembles  that  produced  by  lack  of  food 
and  water.  The  body  is  not  soggy,  but  the  skin  and  both 
other  tissues  are  abnormally  dry.  But  localized  temporary 
edema  is  common  enough  in  carcinoma  of  the  stomach.  It  is 
first  noticed  about  the  ankles,  and  may  appear  early  in  the 
disease.  It  occurs  without  albuminuria  or  cardiac  insuffi- 
ciency, and  comes  and  goes  without  any  changes  in  the  dis- 
eased blood.  The  edema  is  sometimes  confined  to  one  ex- 
tremity, and  is  due  to  phlebitis.  The  occluding  thrombus, 
favored  in  its  formation  by  the  diminished  alkalinity  of  the 
blood,  is  most  frequent  in  the  veins  of  the  lower  extremities, 
34 


530  DISEASES  OF  THE  STOMACH. 

but  may  also  occur  in  other  veins.  Localized  edema  due  to 
venous  thrombosis,  or  fugacious  edema,  unassociated  with 
renal  or  cardiac  insufficiency,  or  with  diarrhea  should  excite 
suspicion  of  malignant  disease.  But,  as  the  rule,  the  cachectic 
emaciation  of  carcinoma  is  progressive  and  dry. 

The  state  of  nutrition  found  in  carcinoma  of  the  stomach 
is  due  partly  to  starvation.  The  appetite  is  diminished,  and 
nearly  always,  in  all  forms  and  localizations  of  carcinoma,  too 
little  food  is  eaten  to  supply  the  needs  of  nutrition.  Tempor- 
ary improvement  may  consequently  often  be  obtained  by  the 
prescription  of  a  carefully  selected  and  sufficient  diet.  The 
emaciation  in  obstruction  of  the  cardia  and  pylorus  is  also 
due  in  part  to  an  insufficient  absorption  of  food.  It  is  very 
common  for  increase  of  weight  and  strength  to  follow  when 
the  obstructed  cardiac  entrance  is  made  free  by  ulceration. 
Improvement  in  the  state  of  nutrition  may  also  be  obtained 
by  surgical  operations  facilitating  the  introduction  and  utili- 
zation of  food,  and  sometimes  by  rectal  feeding.  Still  another 
factor  of  the  emaciation  and  loss  of  strength  in  cancer  of  the 
stomach  is  the  failure  to  digest  and  to  utilize  the  small 
quantity  of  food  which  is  eaten.  The  active  gastric  fermenta- 
tion entails  a  heavy  loss  of  non-nitrogenous  food,  and  the 
almost  constantly  large  quantity  of  indican  in  the  urine  and 
the  foul  odor  of  the  stools  reveal  the  activity  of  putrefaction 
in  the  intestines.  The  continuous  absorption  of  the  products 
of  fermentation  and  putrefaction  exerts  a  deleterious  influence 
on  nutrition. 

But  there  is  still  a  peculiarity  of  catabolism  present  in  car- 
cinoma which  starvation  and  fermentation  and  putrefaction 
do  not  explain.  This  is  the  e.xcessive  nitrogenous  elimination 
due  to  the  active  destruction  of  body  albumin.  This  excessive 
nitrogenous  waste  is  uncontrollable  by  diet,  is  due  to  the  malig- 
nant growth  itself,  and  creates  a  close  resemblance  in  this  re- 
spect between  carcinoma  and  the  infectious  diseases.  It  seems 
probable,  both  from  reasoning  and  experimentation,  that  a 
protoplasmic  poison  is  formed  by  the  neoplasm  and  circulates 
in  the  blood,  to  which  is  due  the  chemotaxis.hematocytolysis, 
leukocytosis,  and  excessive  destruction  of  the  albuminous 
tissues  of  the  body. 

These  many  factors  of  the  emaciation,  cachexia,  and  loss  of 
strength  are  not  equally  active  in  all  cases  of  carcinoma  of 
the  stomach.  Consequently,  too  great  stress  should  not  be 
laid  on  the  state  of  nutrition  at  a  particular  stage  in  the  evo- 
lution of  individual  cases.  The  bod)'  may  remain  pretty  well 
nourished  until  late  in  the  second  half  of  the  course  of  the 


THE   NEOPLASMS   OF   THE   STOMACH.  53 1 

disease.  There  may  be  short  and  temporary  improvement 
and  gains,  which  should  not  be  allowed  to  deceive.  The 
em'aciation  may  be  gradual  and  progressive  from  the  begin- 
ning, or  may  begin  suddenly  in  the  course  of  the  disease  and 
proceed  rapidly.  The  loss  of  weight,  the  weakness,  the  selec- 
tive nitrogenous  waste,  and  the  dry  cachexia  should,  never- 
theless, excite  suspicion  of  a  malignant  disease.  But  these 
signs  are  not  worth  much  in  the  early  diagnosis  of  cancer  of 
the  stomach. 

The  functional  signs  of  carcinoma  of  the  stomach  are  very 
valuable  aids  to  a  correct  and  early  diagnosis.  Neither  the 
hypochylia,  nor  the  motor  insufficiency,  nor  the  diminution  of 
absorption  are  pathognomonic  signs,  but  they  possess  both  a 
positive  and  a  negative  value.  Normal  secretion  and  a  good 
motor  function  speak  emphatically  against  cancer.  Superse- 
cretion  and  hydrochloric  superacidity  possess  great  negative 
value  and  exclude  cancer  where  there  is  no  history  of  ulcer 
or  of  hypersthenic  gastritis. 

In  respect  to  the  functional  signs  carcinoma  may  be  divided 
into  three  forms,  according  to  the  situation  of  the  neoplasm 
on  the  body  of  the  stomach  or  at  one  of  its  orifices.  In 
cancer  involving  the  cardiac  orifice  the  functional  signs  are 
variable;  there  may  be  normal  secretion  and  normal  motor 
activity  throughout  the  disease,  except  in  so  far  as  the  func- 
tions are  modified  by  subnutrition  and  anemia;  or  secretion 
may  be  diminished  if  secondary  asthenic  or  atrophic  gastritis 
should  develop.  In  cancer  of  the  cardia  the  functional  gas- 
tric signs 'are  not  required  for  determining  the  location  of 
the  disease,  and  they  give  very  unimportant  information  con- 
cerning the  nature  of  the  disease.  In  regard  to  the  motor 
function,  it  makes  a  great  difference  whether  the  neoplasm  is 
confined  to  the  body  of  the  stomach  or  whether  it  obstructs 
the  pylorus.  In  the  description  of  the  secretory  signs  the 
situation  of  the  cancer  on  the  body  of  the  stomach  or  close  to 
the  pylorus  need  not  be  kept  in  mind  ;  for  the  secretory 
changes  are  due  to  the  nature  and  extent  of  the  accompany- 
ing gastritis,  and,  to  a  less  degree,  are  the  effect  of  the  sub- 
nutrition,  of  the  toxemia,  and  of  the  anemia. 

Secretion  in  carcinoma  is  diminished  early  in  the  disease, 
often  before  a  tumor  can  be  detected;  and  the  diminution  is 
persistent  from  day  to  day,  and  often  rapidly  progressive.  In 
a  small  number  of  the  cases  of  cancer  nutrition  is  fairly  well 
maintained,  and  the  associated  gastritis  is  slight,  and  secretion 
can  remain  moderately  active  until  near  the  fatal  termination. 
But  the   rule,  nevertheless,  stands  that  in   carcinoma  of  the 


532  DISEASES  OF  THE   STOMACH. 

stomacli  the  free  In-drochloric  acid  soon  disappears,  and 
gradually  the  combined  hydrochloric  acid  decreases  in  the 
contents  obtained  after  a  test-breakfast.  Sinuiltaneously,  the 
pepsin  and  labfernient  and  their  mother-substances  likewise 
decrease,  until  eventually  the  albuminous  foods  undergo  no 
hydrochloric-pepsin  digestion.  The  ferments,  as  in  asthenic 
gastritis,  diminish  in  proportion  with  the  diminution  of  hydro- 
chloric acid  (H  +  C)  secretion.  The  hypochyliais  not  due  to 
the  malignant  growth  itself,  though  the  alkaline  transudate 
from  the  blood-vessels  and  the  cancer  juice  doubtless  often 
neutralize  some  of  the  hydrochloric  acid  secreted.  Nor  is  it 
due  to  the  state  of  nutrition  and  to  the  blood  alone,  though 
the  progressive  cachexia  ma\'  be  an  active  factor.  The  same 
secretory  changes  occur  when  the  cancer  affects  another 
organ,  as  the  uterus  or  the  breast.  Rut  the  state  of  secretion 
is  due  chiefly  to  the  associated  asthenic  gastritis.  The  secre- 
tory signs  are  only  indirect  manifestations  of  the  cancer,  and 
are  in  themselves  in  no  wise  pathognomonic.  Gastric  absorp- 
tion is  diminished,  and  the  diminution  is  persistent  and  pro- 
gressive. 

When  the  cancer  is  engrafted  in  ulcer  it  may  be  accom- 
panied by  secretion  as  rich  as  normal  until  near  its  fatal 
termination  ;  but  it  is  more  common  for  secretion  to 
diminish  as  the  disease  progresses  beyond  a  certain  period. 
In  one  of  our  38  cases  the  cancer  developed  during  the 
course  of  an  old  hypersthenic  gastritis  (no  ulcer),  and 
hyperchylia  persisted  to  fifteen  days  before  death.  In  about 
ten  per  cent,  of  the  cases  of  carcinoma  secretion  remains 
nearly  normal  in  acid  and  in  ferments  until  near  the  end  of 
the  disease.  In  nearly  20  per  cent,  of  the  cases  hypochylia 
develops  slowly.  But  in  the  remainder  of  the  cases  (about 
60  per  cent.),  hypochylia  ben;ins  early  and  develops  rapidly, 
free  HCl  disappearing,  and  the  digestive  power  of  the  con- 
tents varying  from  20  to  near  o,  when  estimated  b}'  the 
method  of  Hammerschlag. 

The  motor  insufficiency  is  a  more  direct  result  of  the  malig- 
nant growth.  The  muscular  layer  becomes  infiltrated  with 
cancerous  cells  and  edematous  from  obstruction  of  the 
lymphatic  circulation.  Late  in  the  disease  the  whole  mus- 
cular system  becomes  weak  from  toxemia  and  wasting.  The 
neoplasm  often  more  or  less  invokes  and  obstructs  the 
pylorus.  The  motor  insufficiency  is,  in  a  large  percentage  of 
the  cases,  an  early  sign,  but  it  becomes  pronounced  more 
rapidly  in  pyloric  carcinoma.  For  a  variable  period  stag- 
nation   exists  ;    first    stagnation    of  solids  only,  and  later  of 


THE   NEOPLASMS  OF   THE   STOMACH.  533 

both  solids  and  liquids.  Retention  follows,  and  the  stomach 
then  always  contains  food  and  liquid.  Retention  occurs 
early  and  almost  invariably  in  pyloric  carcinoma.  The 
only  two  exceptions  which  we  have  seen  were  cases  of 
scirrhus — the  pylorus  being  converted  into  a  functionless 
ring,  the  stomach  being  small  and  evacuating  its  contents 
with  abnormal  rapidity,  achylia  being  complete,  and  lactic 
acid  persistently  absent.  In  cancer  of  the  body  of  the 
stomach  stagnation  is  an  early  sign  in  about  60  per  cent, 
of  the  cases ;  in  a  part  of  the  remainder  stagnation  appears 
late  in  the  disease,  and  about  five  per  cent,  of  the  cases  run 
their  course  without  motor  insufficiency.  Most  important 
characteristics  of  the  motor  insufficiency  of  cancer  are  its 
persistence  and  its  frequently  rapid  increase. 

The  bacteriological  signs  are  in  certain  circumstances  charac- 
teristic of  cancer  of  the  stomach,  and  may  be  so  even  at  an 
early  stage,  when  no  tumor  can  be  detected.  In  no  other  dis- 
ease is  fermentation  more  active,  for  no  other  disease  furnishes 
so  many  favorable  conditions — stagnation,  retention,  hypo- 
chylia,  diminished  absorption,  and  prolonged  salivary  diges- 
tion. 

The  form  of  fermentation  is  not  always  the  same.  Before 
the  disappearance  of  the  free  hydrochloric  acid  and  the  be- 
ginning of  motor  insufficiency,  there  is  no  fermentation  except 
what  may  occur  accidentally  and  temporarily.  As  soon  as 
stagnation  begins,  and  before  the  free  HCl  disappears,  the 
fermentation  is  sometimes  due  to  yeast,  but  is  most  frequently 
butyric.  In  carcinoma  of  the  stomach  butyric  fermentation 
is  almost  as  common  as  lactic  acid  formation,  but  it  is  neither 
persistent  nor  characteristic.  As  the  stagnation  and  hypo- 
chylia  increase,  the  fermentation  becomes  bacillaryand  chiefly 
lactic.  In  no  other  disease  of  the  stomach  is  lactic  acid  so 
frequently  formed  in  large  quantity,  when  certain  precautions 
are  taken  to  prevent  its  introduction  or  its  retention  in  the 
stomach  from  a  previous  meal.  In  the  thoroughly  washed 
stomach  lactic  acid  is  formed  from  food  which  is  perfectly  free 
from  it,  in  quantity  greater  than  one  per  thousand,  in  two- 
thirds  of  the  cases  of  carcinoma  of  the  stomach. 

The  formation  of  lactic  acid  takes  place  in  the  human 
stomach  only  in  very  special  conditions,  and  these  conditions 
are  most  frequently  present  in  carcinoma.  In  the  first  place, 
it  is  absolutely  essential  that  hypochylia  exist  to  such  an  ex- 
tent that  no  free  HCl  is  present  in  the  contents  obtained  one 
hour  after  the  test-breakfast.  Even  the  presence  of  combined 
HCl  in  moderate  quantity  suffices  to  arrest  the  formation  of 


534  DISEASES  OF  THE  STOMACH. 

lactic  acid,  unless  motor  insufficiency  is  so  great  as  to  cause 
retention.  Consequently,  lactic  acid  formation  is  more  fre- 
quently and  persistently  associated  with  absent  free  HCl  and 
nearly  normal  combined  HCl  in  malignant  than  in  benign 
obstruction,  unless  the  cancer  develops  on  an  old  ulcer  or  in  the 
course  of  hypersthenic  gastritis;  for  the  hypochylia  of  carci- 
noma is  persistent  and  progressive,  all  the  constituents  of 
secretion  being  involved.  Lactic  acid  formation  occurs  in  can- 
cer at  a  period  when  the  motor  insufficiency  is  not  so  great  as 
is  required  for  lactic  acid  formation  in  benign  diseases.  This 
clinical  fact  is  probably  due  to  the  accumulation  of  lactic  acid 
forming  bacilli  over  the  portion  of  the  gastric  wall  rendered 
stiff  and  motionless  by  the  neoplasm,  and  to  the  existence  of 
food  retention  in  a  smaller  quantity,  but  persistently,  in  carci- 
noma, at  a  period  when  the  general  motor  insufficiency  is  com- 
paratively not  great.  Lactic  acid  may  be  formed  in  carcinoma 
if  the  tumor  is  extensive  (on  body)  and  uneven,  at  a  time 
when  the  stomach  evacuates  its  contents  in  a  nearly  normal 
period;  but  lactic  acid  formation  never  occurs,  under  such 
circumstances,  in  a  benign  disease.  The  conditions  of  lactic 
acid  formation  are  hypochylia  with  no  free  HCl,  motor  in- 
sufficiency, and  the  accumulation  of  vigorous  lactic  acid  pro- 
ducing germs.  These  conditions  are  seldom  persistently  and 
progressively  fulfilled  to  such  a  degree  that  more  than  i 
per  lOOO  of  lactic  acid  is  formed  during  the  digestion  of 
the  test-breakfast  on  the  morning  following  thorough  lavage 
on  the  preceding  evening,  unless  the  disease  of  the  stomach  is 
cancer. 

Lactic  acid  formation  occurs  invariably  in  cancer  of  the 
pylorus  when  the  obstruction  becomes  sufficient  to  produce 
retention  and  there  is  no  free  HCl  in  the  contents  after  the 
test-breakfast.  But  lactic  acid  formation  may  occur  in  benign 
retention  with  hypochylia,  and  great  precaution  must  be  taken 
in  interpreting  lactic  acid  formation  in  obstructive  retention. 
In  two-thirds  of  the  cases  of  cancer  situated  on  the  body  of  the 
stomach  there  is  lactic  acid  formation  in  quantity  greater  than 
I  per  lOOO.  Consequently,  the  absence  of  lactic  acid  formation 
does  not  exclude  cancer  of  the  pylorus  before  retention 
occurs  ;  nor  does  it  exclude  a  cancer  of  the  body  of  the  stom- 
ach, whatever  be  the  stage  of  its  growth.  In  109  cases  of 
disease  of  the  stomach  with  hypochylia  we  have  found  lactic 
acid  in  quantity  greater  than  I  per  2000  in  44  cases ;  38  of 
the  109  cases  were  carcinoma,  and  in  31  of  the  38  cases  lactic 
acid  formation  was  present.  In  132  cases  with  hyperchylia 
we  have  found  cancer  3  times — 2  engrafted  on  ulcer  and  i  on 


THE   NEOPLASMS   OF   THE   STOMACH.  535 

chronic  hypersthenic  gastritis.  Hammerschlag,  in  250  cases 
of  diseases  of  the  stomach,  found  lactic  acid  in  35,  and  29  of 
these  35  cases  were  cases  of  carcinoma.  In  153  cases  Strauss 
found  lactic  acid  in  27  and  cancer  in  22.  In  14  cases  of  cancer 
of  the  stomach  Klemperer  found  lactic  acid  in  12  ;  in  42  cases 
of  the  same  disease  Hammerschlag  reports  no  free  HCl  in  37, 
digestive  power  less  than  20  per  cent,  in  30,  and  lactic  acid  in 
26;  Boas  found  lactic  acid  in  30  out  of  40  cases.  In  55  cases 
of  cancer  of  the  stomach  Hayem  found  achylia  in  6,  hypo- 
chylia  with  no  free  HCl  in  48,  hyperchylia  (with  disappear- 
ance of  free  HCl  in  one  month)  in  i,  and  lactic  acid  in  25. 
These  statistics  give  a  general  idea  of  the  frequency  and  diag- 
nostic value  of  lactic  acid  formation  in  cancer  of  the  stomach. 

When,  in  the  course  of  cancer,  obstructive  retention  devel- 
ops, the  fermentation  becomes  mixed.  The  gas-forming 
germs  now  become  active.  The  kinds  of  micro-organisms 
change  during  the  course  of  cancer,  as  do  the  forms  of  fer- 
mentation. Sarcinae  are  only  found  when  retention  coexists 
with  secretion  so  active  as  to  leave  HCl  free;  lactic  acid  fer- 
mentation destroys  them  rapidly,  and  they  are  not  found  in 
association  with  it  except  isolated  and  dying.  Lactic  acid 
formation  is  accompanied  by  the  bacillus  geniculatus.  In  the 
mixed  fermentations  are  found  bacilli  and  yeasts.  There  is 
no  H2S  formation  in  malignant  disease  of  the  stomach  (Boas). 

The  anatomical  signs  are  inconstant,  but  may  be  absolutely 
demonstrative,  revealing  the  malignant  disease  to  the  eye. 
The  washings  and  vomit  should  be  repeatedly  and  persistently 
examined  for  pieces  of  the  tumor.  A  negative  result  is  with- 
out meaning,  but  the  discovery  of  little  pieces  of  the  mucous 
membrane  showing  the  histological  characters  of  asthenic 
gastritis  does  not  exclude  carcinoma. 

Another  very  important  anatomical  sign  is  the  presence  of 
pus  and  cancer  cells  in  the  vomit  or  expressed  contents. 
There  is  no  pepsin-hydrochloric  digestion,  or  very  little, 
in  the  stage  of  carcinoma  when  ulceration  is  active.  Con- 
sequently, the  dead  tissue  and  the  inflammatory  products 
are  not  digested  as  in  ulcer,  and  the  motor  insufficiency  of 
carcinoma  makes  the  obtaining  of  them  in  the  vomit  and  wash- 
ings all  the  more  likely.  It  should  not  be  forgotten  that  the 
pus  may  be  swallowed,  and  it  is  only  a  confirmatory  sign, 
except  when  mixed  with  the  debris  of  cancerous  tissue  which 
can  be  recognized  as  gastric. 

The  blood  changes  in  cancer  of  the  stomach  are  not  in  them- 
selves characteristic,  but  are  very  marked,  progressive,  and 
possess  some  diagnostic  value.     The    anemia  may  be  mild. 


536  DISEASES  OF  THE  STOMACH. 

severe,  or  grave,  and  is  not  accompanied,  as  a  rule,  by  hemic 
murmurs  in  the  heart  and  tlie  blood-vessels. 

Cancer  of  the  stomach  produces  greater  changes  of  the 
blood  than  does  cancer  of  any  other  organ  of  the  body.  The 
pathological  blood  alterations  are  due  to  subnutrition,  to 
hemorrhage,  to  toxemia,  and  to  the  low  reparative  power  of 
the  body,  and  affect  the  development  of  the  blood,  the  vitality 
and  resisting  power  of  the  corpuscles,  and  the  composition  of 
the  plasma. 

Coagulation  and  fibrin  formation  are  normal  or  less  active 
than  in  health.  Rapid  and  excessive  fibrin  formation  does 
not  occur  in  cancer  unless  it  is  complicated  by  inflammation. 

The  specific  gravity  of  the  blood  is  always  reduced,  and  to 
a  greater  extent  than  would  be  indicated  by  the  diminution  of 
the  hemoglobin,  unless  leukocytosis  and  other  counteracting 
influences  are  present.  The  specific  gravity  of  the  blood, 
which  can  be  easily  estimated  by  the  method  of  Hammer- 
schlag,  is  determined  by  the  number  and  size  of  the  red  cor- 
puscles, by  the  quantity  of  hemoglobin,  by  the  quantity  of 
water,  by  the  richness  of  the  plasma  in  albumin  and  salts,  and 
by  the  number  of  leukocytes.  In  cancer  there  is  always  a 
diminution  of  the  hemoglobin  below  the  percentage  which 
would  be  indicated  by  the  number  of  red  corpuscles;  but  the 
average  size  of  the  red  corpuscles  may  be  diminished,  the 
quantity  of  water  may  be  so  greatly  reduced  as  to  produce 
oligemia  sicca,  the  plasma  may  be  poor  and  thin,  and  the 
number  of  leukocytes  may  be  greatly  increased.  Conse- 
quently, the  specific  gravity  does  not  increase  and  decrease 
with  the  percentage  of  hemoglobin  ;  but  it  may  so  happen 
that  the  combined  effect  of  the  other  factors  is  multiplied,  or 
they  may  work  more  or  less  in  unison  to  reduce  or  increase 
the  specific  gravity.  The  specific  gravity  of  the  blood  is 
characteristic  of  the  blood  of  cancer  only  when  its  relation 
to  all  the  factors  which  influence  it  is  known. 

In  cancer  of  the  stomach  the  quantity  of  hemoglobin  and 
the  number  of  red  corpuscles  steadily  decrease  from  the 
moment  the  blood  is  altered  by  the  malignant  disease  until 
death  arrests  the  process.  There  is  in  reality  progressive 
descent;  but  this  descent  may  be  masked  by  the  occurrence 
of  oligemia  sicca,  which  may  cause  the  percentage  of  hemo- 
globin and  the  number  of  corpuscles  to  approach  or  return  to 
the  normal  percentage  and  number.  But  the  oligemia  sicca 
only  masks  the  anemia,  which  is  easily  detected  by  the  micro- 
scope and  by  stains. 

The  hemoglobin  percentage   in  cancer  of  the  stomach  is 


THE   NEOPLASMS    OF   THE   STOMACH.  537 

always  less  than  the  percentage  of  red  corpuscles,  because 
the  average  size  of  the  red  corpuscles  is  nearly  always  less 
than  the  average  normal  size,  and  the  regeneration  of  hemo- 
globin is  deficient.  The  persistence  of  this  condition  in  the 
absence  of  signs  of  regeneration  of  the  blood  is  a  marked 
characteristic  of  carcinomatous  blood. 

The  blood's  losses  in  cancer  of  the  stomach  are  nearly 
always  permanent.  Even  after  an  operation,  when  blood  is 
destroyed  by  the  anesthetic  and  lost  by  hemorrhage,  the  loss 
is  very  slowly  and  incompletely  restored,  even  though  the 
operation  greatly  improves  nutrition  and  the  functions  of  the 
stomach.  The  cancer  produces  obstinate  insufficiency  of  the 
blood-building  organs. 

The  red  corpuscles  undergo  qualitative  alterations.  The 
average  size  is  less  than  normal,  and  a  glance  at  a  specimen 
under  the  microscope  will  reveal  the  large  number  of  micro- 
cytes,  rendering  it  seldom  necessary  to  compare  the  volume 
percentage  given  by  the  hematocrit  with  the  percentage  of 
counted  red  corpuscles.  But  in  the  grave  stage  of  the  anemia 
megalocytes  may  appear  ;  but  many  of  these  are  imbibition 
corpuscles.  The  red  corpuscles  also  degenerate  and  undergo 
destruction  in  the  circulating  blood.  The  blood  becomes 
poor  in  chlorids  and  nitrogenous  substances,  and  a  proto- 
plasmic poison  is  formed  in  cancer  of  the  stomach. 

The  white  corpuscles  in  cancer  of  the  stomach  may  undergo 
quantitative  and  qualitative  alterations.  The  number  of  white 
corpuscles  is  decreased  by  the  subnutrition  and  by  the  low 
vitality;  and  their  number  is  increased  by  hemorrhage,  by 
hematocytolysis,  by  metastases,  by  peritonitis,  and  other 
inflammatory  complications,  and  by  strong  reaction  of  the 
organism  when  it  still  possesses  some  power  of  resistance. 
The  number  of  white  corpuscles  is  the  result  of  the  struggle 
between  these  factors,  and  leukocytosis  is  present  in  more 
than  half  of  the  cases.  But  cancer  of  the  stomach,  particu- 
larly when  it  obstructs  one  of  the  orifices,  and  when  it  is  not 
accompanied  by  an  inflammatory  complication,  may  run  its 
entire  course  with  a  normal  or  diminished  (terminal  leuko- 
penia) number  of  leukocytes.  During  the  clinical  stage  of 
carcinomaof  the  stomach  digestive  leukocytosis  seldom  occurs. 
The  insufficient  blood-building  organs  do  not  respond  to  the 
demands  of  digestion,  absorption,  and  assimilation.  The 
number  of  white  corpuscles  three  hours  after  a  rich  meal,  in- 
cluding proteids  and  fats,  is  not  materially  different  from  the 
number  of  leukocytes  counted  before  the  meal.  Myelocytes 
are  frequently  found  in  the  blood  of  cancer,  and  the  leuko- 


538  DISEASES  Of  THE  STOMACH. 

cytes  undergo  degeneration  in  greater  and  greater  numbers 
as  the  blood  alterations  increase.  The  nucleus  of  the  lympho- 
cytes becomes  poorer  and  poorer  in  chromatin  as  the  cyto- 
plasm disappears ;  loses  its  form  and  structure ;  enlarges 
and  finally  undergoes  dissolution.  The  polynuclear  leuko- 
cytes are  affected  by  hyperchromatosic  degeneration.  As 
many  as  ten  per  cent,  of  the  leukocytes  may  be  degenerated, 
and  these  degenerate  corpuscles  go  to  pieces  in  the  circula- 
tion, appearing  as  formless  protoplasmic  masses  in  the  fresh 
and  the  stained  preparations  of  the  blood. 

The  alkalinity  of  the  blood  is  diminished  in  carcinoma  of 
the  stomach.  This  is  doubtless  due,  in  part,  to  the  increased 
destruction  of  body  albumin,  whereby  sulphuric,  phosphoric, 
lactic,  and  oxybutyric  acids  are  set  free.  I^ut  the  exces- 
sive acid  fermentation  and  the  putrefaction  of  which  the  diges- 
tive tube  is  the  theater  also  exert  a  noteworthy  influence. 

The  urine  changes  in  carcinoma  of  the  stomach  are  very 
marked,  but  no  one  singly,  nor  all  taken  together,  enable  us 
to  infer  the  existence  of  the  cancer.  The  normal  digestive 
curve  of  diminishing  acidity,  which  reaches  its  highest  point 
between  three  and  five  hours  after  a  meal,  is  seldom  found  in 
cancer  of  the  stomach,  and  this  is  plausibly  explained  by  the 
small  quantity  of  hydrochloric  acid  secreted.  The  twenty- 
four  hours'  urine  may  be  constantly  almost  neutral,  and  this 
may  be  due  to  the  absorbed  organic  acids  and  ammonia  pro- 
duced by  gastro-intestinal  fermentation  and  putrefaction.  On 
the  other  hand,  the  acidity  of  the  urine  is  often  increased,  and 
uric  acid  precipitation  is  frequent.  The  reaction,  though  pre- 
senting variations,  is  of  no  diagnostic  value. 

The  uric  acid  elimination  is  sometimes  largely  increased, 
as  would  naturally  be  expected,  in  leukocytosis,  in  active 
destruction  of  body  albumin,  and  in  acid  toxemia.  The  sec- 
ondary insufficiency  of  the  liver  seems  also  to  exert  some 
influence  in  causing  uric  acid  precipitation.  Almost  con- 
stantly, in  cancer  of  the  stomach,  more  nitrogenous  matter 
is  eliminated  than  is  introduced  with  the  food.  The  excessive 
nitrogenous  elimination  represents  the  excessive  destruction 
of  body  albumin  ;  but  on  account  of  the  insufficiency  of  the 
food  the  total  elimination  of  nitrogenous  matter  is  commonly 
less  than  in  health.  When  little  food  is  digested  and  utilized 
and  the  emaciation  is  advanced,  the  elimination  of  urea,  and 
also  of  the  chlorids,  falls  very  low. 

The  urine  often  contains  urobilin,  particularly  when  the 
liver  becomes  secondarily  involved  or  when  the  red  cells 
rapidly    disintegrate.       Indican    is   largely  and    almost   con- 


THE   NEOPLASMS   OE   THE   STOMACH.  539 

stantly  increased.  Albumoses  may  also  be  found  in  the 
urine,  particularly  when  the  neoplasm  undergoes  rapid  ulcera- 
tion. Acetonuria  is  a  frequent  terminal  sign,  and  the  urine 
may  contain,  particularly  where  there  is  coma,  traces  of  oxy- 
butyric  acid.  The  urine  signs  demonstrate  how  severely 
nutrition  is  affected,  but  possess,  on  account  of  not  being 
peculiar  to  cancer  of  the  stomach,  an  exceedingly  small 
diagnostic  value. 

In  the  majority  of  the  cases  of  cancer  of  the  stomach  the 
bowels  are  constipated  until  the  beginning  of  the  last  few 
weeks,  when  diarrhea  commences.  Sometimes  the  stools 
are  frequent,  and  sometimes  dysenteric;  but  more  commonly 
every  one  or  two  days  there  is  a  large,  foul,  and  loose  move- 
ment. In  about  one-third  of  the  cases  constipation  persists 
from  the  beginning  to  the  termination,  an  incomplete  evacua- 
tion of  the  bowels  occurring  every  four  or  five  days,  and  the 
stool  consisting  of  hard  lumps  of  intestinal  secretion,  and 
of  a  quantity  of  undigested  muscular  fibers.  The  constipa- 
tion is  most  obstinate  when  the  cardia  is  obstructed.  In 
pyloric  cancer  the  course  is  broken  by  diarrheal  attacks. 
Unmixed  lactic  acid  fermentation  favors  constipation. 

The  stools  sometimes  contain  blood.  Traces  of  blood  are 
frequently  found,  and  melena  is  usual  when  the  vomit  con- 
tains much  blood  or  is  colored  like  coffee  grounds. 

Carcinoma  of  the  stomach  is  an  afebrile  disease.  But  fever 
may  occur  during  its  course,  and  may  be  due  to  a  compli- 
cation, such  as  perigastritis,  subphrenic  abscess,  peritonitis-, 
pleurisy,  pericarditis,  or  to  a  secondary  cancerous  deposit 
which  excites  inflammation.  Fever  may  also  occur  as  a 
symptom  of  an  associated  disease ;  but  febrile  exacerbations 
may  sometimes  be  present  without  any  discoverable  cause 
except  the  cancer  itself  or  an  ulceration  of  the  neoplasm.  The 
fever  peculiar  to  cancer  is  intermittent,  beginning  with  a  chill, 
ending  with  free  perspiration,  and  recurring  irregularly,  re- 
sembling closely  a  malarial  chill,  and  is  most  plausibly  ex- 
plained as  an  acute  auto-intoxication.  In  the  cachectic  stage 
the  temperature  is  usually  subnormal  continuously,  but  it 
may  rise  intermittently  to  the  normal  point,  the  pulse  becom- 
ing more  rapid  and  the  patient  complaining  of  feeling  hot.  A 
slight  rise  of  temperature  during  the  height  of  digestion'  is 
quite  common. 

Cancer  of  the  stomach  sometimes  ends  in  coma,  which 
may  be  preceded  by  inanition  delirium.  The  patient  falls 
into  a  stupor,  the  breathing  becomes  deep  and  stertorous,  the 
pulse  rapid,  the  muscles  sometimes  twitch,  or  there  may  be 


540  DISEASES  OF  THE  STOMACH. 

general  convulsions.  The  coma  ends  fatally  in  from  one  to 
three  da\-s. 

Diagnosis — The  diagnosis  of  carcinoma  of  the  stomach 
may  be  easy,  difficult,  or  impossible.  Consequently,  the 
physician  may  be  certain,  doubtful,  or  without  suspicion  of  the 
existence  of  a  cancer  in  a  particular  case.  Modern  methods 
of  examination  reveal  the  disease  when  formerly  it  would 
have  been  overlooked. 

From  a  diagnostic  view-point  the  cases  can  be  divided 
into  two  large  classes,  accordingly  as  a  tumor  can  or  can  not 
be  detected. 

If  a  tumor  be  found,  the  examination  should  be  so  con- 
ducted as  to  determine  whether  the  tumor  is  gastric  and 
malignant,  and  where  it  is  located  on  the  stomach.  When  no 
tumor  can  be  detected,  the  diagnosis  may  have  to  be  made 
early  in  the  disease,  while  radical  surgical  treatment  is  prac- 
ticable ;  or  late,  when  palliation  is  the  only  aim.  But  it  should 
not  be  forgotten  that  a  tumor  so  located  as  to  be  easily 
accessible  to  physical  examination  maybe  discovered  early  in 
the  disease. 

A  tumor  of  the  stomach  may  be  found  in  almost  any  part 
of  the  abdomen  to  which  the  displaced  or  enlarged  stomach 
extends.  Consequently,  the  search  should  not  be  limited  to 
the  small  area  of  the  normal  stomach,  nor  should  those 
tumors  found  within  this  area  be  supposed  to  belong  neces- 
sarily to  this  organ.  Outside  of  this  narrow  field  gastric 
tumors  are  also  found.  It  is  often  necessary  to  differentiate 
the  tumors  of  the  stomach  from  possible  tumors  of  other 
abdominal  organs,  such  as  the  liver,  spleen,  gall-bladder, 
duodenum,  colon,  kidneys,  mesentery  ;  and  also  to  differentiate 
them  from  abdominal  abscess  and  from  abdominal  aneurysm. 

Very  valuable  information  is  often  furnished  by  the  clinical 
history.  A  malignant  palpable  tumor  of  the  stomach  invari- 
ably produces  gastric  symptoms  and  signs.  Carcinoma  of 
other  organs  may  disturb  their  functions  in  a  manner  notice- 
able by  the  patient.  But  the  subjective  symptoms  should 
simply  draw  the  attention  in  a.  particular  direction,  for  they 
may  be  due  to  secondary  deposits,  to  complications,  or  to 
associated  non-malignant  disease.  The  stomach  is  more  likely 
to  be  disturbed  than  is  any  other  organ,  being  a  center  for 
the  expression  of  so  many  abdominal  diseases.  Conse- 
quently, the  total  absence  of  gastric  disorder  is  a  very  valu- 
able negative  sign. 

The  physical  signs  are  often  more  direct  and  conclusive. 
The  tumor  of  the  stomach  can  be  seen  or  felt  only  in  the  re- 


THE   NEOPLASMS    OF   THE   STOMACH.  54I 

gion  occupied  by  the  stomach  in  the  particular  case.  Conse- 
quently, the  exact  location  of  the  stomach  by  percussion,  by 
inflation,  by  splashing,  by  filling  the  organ  with  water,  by  pal- 
pation of  the  balloon  sound,  and  by  electric  illumination  may 
be  of  great  value.  Not  only  is  the  tumor  thus  located  within 
or  without  the  gastric  area,  but  other  valuable  information 
may  be  obtained.  After  inflation  the  tumor  may  be  seen  or 
felt  to  belong  to  the  stomach,  and  to  be  more  clearly  and 
widely  separated  from  surrounding  organs.  The  tumor,  which, 
during  inflation,  was  surrounded  by  a  tympanitic  area,  may, 
after  filling  the  stomach  with  water,  be  surrounded  by  a  duller 
or  flat  zone,  and  be  within  the  area  of  gastric  splashing.  The 
tumor  may  present  a  dark  spot  on  the  illuminated  stomach,  a 
phenomenon  which  is  very  interesting,  but  possesses  very 
little  diagnostic  value  unless  clearer  and  more  conclusive 
methods  of  examination  are  neglected.  The  tumor  may  be 
revealed  by  inflation,  or  may  thereby  be  made  more  perceptible, 
or  its  position  may  be  changed,  or  it  may  be  palpable  and 
visible  only  when  the  stomach  is  empty.  The  tumors  of  the 
colon  and  mesentery  are  simply  pressed  downward  by  inflation 
of  the  stomach  ;  those  of  the  left  lobe  of  the  liver  are  pressed 
upward  and  forward  ;  and  those  of  the  spleen,  downward,  and 
outward,  and  forward,  against  the  abdominal  wall.  The  tumors 
of  the  greater  curvature  and  the  anterior  wall  are  rolled  and 
pressed  forward ;  those  of  the  lesser  curvature  disappear 
upward  and  backward ;  and  those  of  the  pylorus  are  pressed 
downward  and  to  the  right,  or  to  the  right  and  upward,  and 
may  be  made  inaccessible  to  palpation  if  the  pyloric  pouch  is 
much  dilated.  All  these  special  signs  should  be  noted  and 
taken  in  evidence  when  the  conclusion  is  formed. 

The  tumors  of  the  stomach  also  present  peculiarities  in 
relation  to  the  movements  of  the  diaphragm  during  respiration. 
The  closer  and  more  direct  the  connection  of  the  tumor  of 
the  stomach  to  the  diaphragm,  the  greater  and  more  constant 
are  its  respiratory  movements.  It  is  easy  to  demonstrate  by 
the  gliding  method  of  palpation  that  even  the  greater  curva- 
ture of  the  stomach  moves  up  and  down  with  the  relaxation 
and  contraction  of  the  diaphragm  ;  and,  consequently,  the 
contention  that  tumors  located  on  this  part  of  the  stomach 
are  unchanged  in  their  position  by  respiration  is  false.  The 
extent  of  their  mobility  is  limited  by  the  increase  of  intra- 
abdominal pressure.  The  up-and-down  movement  is  greatest 
when  the  lateral  expansibility  of  the  abdomen  is  small,  and 
the  intra-abdominal  pressure  in  the  part  of  the  abdomen 
inferior    to    the    tumor    is    least.     Wherever    the    abdominal 


542  DISEASES  OF  THE   STOMACH. 

tumor  be  located,  its  respiratory  mobility  will  depend  on 
the  solidity  of  the  pressure  exerted,  directly  or  indirectly,  by 
the  diaphragm  ;  on  the  freedom  of  the  organ  from  restricting 
ligaments  and  adhesions ;  and  on  the  degree  of  resistance 
offered  by  the  parts  below  the  tumor. 

It  can  easily  be  inferred  that  the  tumors  of  the  pancreas 
and  kidneys,  if  firmly  and  closely  attached  to  these  organs, 
remain  stationary  during  respiration;  those  of  the  liver  and 
spleen  (except  when  these  organs  are  displaced  and  their 
attachments  are  weak)  follow  closely  the  movements  of  the 
diaphragm  ;  and  the  tumors  of  the  colon,  mesentery,  and 
a  large  portion  of  the  stomach  are  not  necessarily  so  greatly 
changed  in  their  position  by  the  act  of  respiration. 

The  relation  of  the  movable  tumors  to  expiration  fur- 
nishes another  differential  sign.  If  at  the  end  of  inspiration 
the  tumor  be  caught  along  its  upper  border  by  the  exam- 
ining fingers,  it  may  or  may  not  be  capable  of  fixation  during 
expiration.  The  tumors  of  the  liver  and  spleen,  unless  these 
organs  be  pathologically  movable,  can  not  be  thus  fixed.  In 
order  to  arrest  the  expiratory  movement  of  the  tumors  of 
the  lesser  curvature  and  pylorus  when  their  attachments  are 
not  weakened,  a  good  deal  of  force  is  required ;  but  the 
tumors  of  the  colon,  greater  curvature,  and  greater  omentum 
are  more  easily  fixed,  and  when  released  slip  up  with  little 
force.  These  respiratory  peculiarities  of  abdominal  tumors 
are  converted  by  educated  and  experienced  palpation  into 
valuable  differential  signs. 

Another  palpation  sign  is  valuable  in  the  diagnosis  of  the 
tumors  of  the  pylorus,  which  are  often  hard  and  solid  to  the 
touch.  If  the  tumor  be  held  beneath  the  fingers,  particularly 
soon  after  a  meal,  gas  can  be  felt  bubbling  intermittently 
through  it.  An  intermittent  pyloric  spurt  may  often  be  heard 
with  the  stethoscope  placed  over  the  point.  If  the  stomach 
be  empty,  the  signs  are  best  sought  after  the  administration 
of  a  glass  of  water  about  the  time  that  a  meal  is  usually  eaten, 
for  active  gastric  peristalsis  recurs  regularly  and  periodically 
after  each  mealtime.  When  the  bubbling  is  felt  and  the  spurt 
heard  under  these  conditions,  the  solid  tumor  can  be  only 
pyloric.  The  only  possible  source  of  error  is  an  annular 
tumor  of  the  intestines,  which,  only  in  very  special  and  rare 
circumstances,  can  give  rise  to  somewhat  similar  signs. 

Percussion  may  also  give  some  information.  Percussion 
over  a  tumor  of  the  stomach  which  is  not  strictly  limited  to 
one  of  the  orifices  is  never  dull  if  the  organ  contain  gas. 
Percussion  over  a  solid  tumor  situated  beneath  or  over  a  hoi- 


THE  NEOPLASMS    OE    THE   STOMACH.  543 

low  organ  is  tympanitic.  The  tumor  may  often  be  sur- 
rounded and  separated  from  adjacent  organs  by  a  zone  of  a 
different  percussion  note.  Tlie  note  over  the  surrounding 
area  may  be  changed  by  inflation  of  the  stomach.  Valuable 
differential  physical  information  may  often  be  obtained  by 
inflating  the  colon  with  air  or  by  filling  it  with  water;  or 
more  information  may  sometimes  be  ascertained  by  simul- 
taneously filling  the  stomach  with  gas  and  the  colon  with 
water;  or  by  palpation  of  the  introduced  balloon  sound 
inflated  to  about  the  size  of  the  fist. 

The  functions  of  the  stomach  are  never  normal  when  it  is 
the  seat  of  a  palpable  new  growth.  Persistently  excessive 
secretion  should  excite  suspicion  of  a  gastric  ulcer  as  the 
cause  of  the  tumor.  A  diminution  of  secretion  may  be  pres- 
ent in  the  course  of  malignant  disease,  wherever  located,  and 
is  hardly  available  as  a  differential  sign.  The  bacteriological 
signs  may  not  only  locate  the  tumor  in  the  stomach,  but 
reveal  its  nature,  as  would  also  a  piece  of  the  tumor  in  the 
vomit  or  washings.  Pus  in  the  contents,  if  it  has  not  found 
entrance  through  the  cardia  and  is  present  in  noteworthy 
quantity,  signifies  that  an  abscess  has  opened  into  the  stomach 
or  that  there  is  ulceration  and  pus  formation  associated  with 
insignificant  gastric  digestion.  Pus  is  seldom  found,  but 
cancer  cells  are  sometimes  numerous,  and  both  may  aid  in 
connecting  the  tumor  with  the  stomach. 

Tumors  of  the  stomach  must  be  so  often  distinguished 
from  those  of  the  liver  and  transverse  colon  that  a  special 
grouping  of  the  differential  signs  is  desirable.  The  tumors  of 
the  transverse  colon  produce  intestinal  stagnation  above  the 
obstruction  or  at  the  part  of  the  bowel  where  the  muscular 
coat  is  rendered  inactive  by  the  tumor.  The  hypertrophied 
wall  may  show  visible  peristaltic  waves,  and  the  fingers  or 
the  stethoscope  placed  upon  the  tumor  may  enable  us  to  feel 
or  to  hear  the  intestinal  contents  bubbling  through  it.  The 
tumors  of  the  pylorus  also  present  these  signs,  but  in  relation 
with  visible  or  palpable  gastric  peristalsis.  The  tumors  of 
the  colon  disturb  the  motor  function  of  the  bowel,  but  not 
that  of  the  stomach.  By  inflation  of  the  colon  the  tumors 
of  the  stomach  are  displaced  upward,  while  those  of  the 
colon  do  not  rise,  but  may  be  revealed  to  a  greater  extent, 
and  their  origin  in  the  colon  may  be  made  clearer.  By  in- 
flation of  the  stomach  the  tumors  of  the  colon  are  pressed 
downward,  those  of  the  lesser  curvature  of  the  stomach 
disappear,  the  pyloric  tumor  goes  downward  and  to  the  right 


544  D/SE.ISES  OF  rilE  STOMACH. 

or  is  concealetl  b)^  the  dilated  pyloric  pouch,  and  those 
located  on  the  anterior  wall  and  greater  curvature  become 
apparently  larger  and  less  sharply  defined.  It  should  never 
be  forgotten  that  the  colon  may  lie  between  the  stomach  and 
the  anterior  abdominal  wall,  and  before  locating  a  tumor  in 
this  region  the  position  of  the  bowel  should  be  determined 
by  inflation.  Tiie  tumors  of  the  colon  can  always  be  fi.xed 
on  expiration. 

The  tumors  of  the  liver  can  not  be  fixed  on  expiration 
unless  the  whole  organ  be  prevented  from  rising, — which  only 
happens  when  its  attachments  are  weakened, — and  they  are 
pushed  upward  and  forward  by  inflation  of  the  stomach  and 
colon.  The  tumor  of  the  liver,  however,  may  be  secondary. 
Primary  carcinoma  of  the  liver,  which  is  rare,  produces  rapid 
and  great  enlargement  of  the  organ,  and  icterus  often  appears 
early.  A  tumor  of  the  liver  with  round  margins  and  a  cen- 
tral cupping  is  always  a  secondary  cancer,  and  if  the  stomach 
presents  the  functional  and  bacteriological  signs  of  carci- 
noma, this  organ  is  the  seat  of  the  primary  disease,  although 
no  gastric  tumor  be  felt. 

A  tumor  of  the  gall-bladder  is  felt  attached  to  the  liver 
at  the  normal  position  of  this  receptacle.  It  may  often,  when 
the  cystic  duct  is  obstructed,  be  moved  some  distance  to  the 
left,  toward  the  median  line,  and  follows  closely  the  phreno- 
hepatic  respiratory  movements.  Tiiere  is  no  motor  disturb- 
ance of  the  stomach  unless  the  duodenum  be  compressed, 
when  bile  may  flow  continuously  into  the  stomach  and  gas- 
tric obstructive  retention  may  develop.  The  pjdoric  tumor 
may  be  readily  differentiated  by  the  pyloric  bubbling,  which 
may  be  felt  with  the  fingers  or  heard  with  the  stethoscope. 

A  tumor  of  the  stomach  is  either  benign  or  malignant,  and 
it  is  of  the  utmost  clinical  importance  that  the  two  varieties 
should  be  sharply  differentiated.  Fibroma,  myoma,  adenoma, 
and  gastroliths  are  very  rare.  More  frequent  is  a  palpable 
resistant  mass  formed  by  the  whole  stomach  or  by  an  inflam- 
matory exudate. 

The  benign  neoplasms  produce  no  metastases,  are  slow  in 
their  development,  produce  often  but  slight  functional  dis- 
turbance, and,  except  when  obstructing  an  orifice,  cause  no 
progressive  emaciation  and  cachexia,  develop  often  at  an 
early  age,  and  are  neither  nodulated  nor  hard. 

The  gastric  tumor  may  be  formed  of  the  whole  organ. 
The  tumor  formed  by  the  distended  stomach  disappears  when 
tile  organ   is  emptied.     In  only  three   diseases  is  the  tumor 


THE   NEOPLASMS   OF   THE   STOMACH.  545 

formed  by  the  wall  of  the  stomach — in  chronic  interstitial 
or  fibrous  gastritis,  in  disseminated  scirrhus,  and  in  the  small 
retracted  stomach  of  obstruction  of  the  cardia.  Between 
the  benign  and  malignant  affections  the  clinical  history  and 
the  evolution  often  discriminate.  Disseminated  hard  cancer 
may  run  a  slow  course,  however,  and  metastases  and  enlarged 
glands  often  can  not  be  detected.  Obstruction  of  the  cardia 
should  excite  suspicion  of  the  small  retracted  stomach  which 
does  not  lose  its  peristaltic  power.  In  scirrhus  and  in  cir- 
rhosis ventriculi  the  stomach  is  an  almost  inert  tube.  Conse- 
quently, pyloric  bubbling  and  visible  or  palpable  peristalsis, 
however  excited,  decide  against  hard  cancerous  infiltration. 

An  inflammatory  palpable  exudate  is  nearly  always  the 
result  of  gastric  ulcer.  An  ulcer  history  would  decide  the 
nature  of  the  tumor  were  not  cancer  sometimes  engrafted  in 
an  ulcer.  The  differentiation  can  not  be  made  unless  a  sec- 
ondary cancer  deposit  be  found.  Excessive  or  normal  secre- 
tion, blood  crises,  digestive  leukocytosis,  simple  inanition 
without  excessive  destruction  of  body  albumin,  are  against 
the  ulcer  having  become  cancerous,  which,  it  should  also  be 
remembered,  occurs  only  in  a  very  small  percentage  of  the 
cases  of  ulcer. 

The  tumor  is  more  likely  to  be  cancerous  the  more  closely 
the  evolution,  symptoms,  and  signs  are  those  of  a  malignant 
disease.  An  unaccountable  and  insidious  beginning  in  a 
person  beyond  the  thirtieth  year  who  has  previously  enjoyed 
good  digestion,  progressive  evolution,  increasing  diminution 
of  secretion,  motor  insufficiency,  lactic  acid  fermentation  pro- 
duced by  bacilli,  emaciation,  and  loss  of  strength,  excessive 
waste  of  body  albumin,  the  inefficiency  of  treatment — all 
favor  cancer. 

The  difficulty  of  determining  the  nature  of  the  tumor  is 
greater  when  the  pylorus  is  involved.  Is  the  obstruction  due 
to  ulcer,  to  cancer,  or  to  benign  muscular  hypertrophy?  If 
the  tumor  extends  on  to  the  body  of  the  stomach,  it  is  more 
likely  to  be  cancer,  and  is  most  probably  so  if  the  bacterio- 
logical signs  of  cancer  be  present.  If  the  tumor  forms  and  the 
obstruction  develops  in  the  course  of  ulcer,  the  tumor  is  most 
likel}^  benign,  and  is  most  certainly  so  if  there  are  no  functional, 
bacteriological,  or  malignant  nutritive  signs  present. 

Annular  scirrhus  and  hypertrophy  of  the  pylorus  are  so 
closely  alike  as  to  leave  nearly  always  a  large  place  for  doubt. 
If  the  patient  has  been  long  under  observation,  the  slow 
growth  of  the  smooth  hard  tumor  and  the  long  duration  of 
the  trouble  speak  in  favor  of  hypertrophy.  Nutrition  may 
35 


546  DISEASES  OF   7 HE   STOMACH. 

be  improved  materially  by  a  proper  diet  and  b\'  nutrient 
enemata.  But  if  the  characteristic  functional  and  bacterio- 
logical signs  of  cancer  are  not  present,  the  trouble  is  most 
probably  not  malignant.  Metastasis,  nodulation,  and  enlarg- 
ment  of  the  glands  close  to  the  pylorus  may  characterize  the 
annular  cancer  of  the  pylorus.  The  infiltrated,  cancerous 
pyloric  ring  does  not  contract  or  relax  perceptibly,  as  does 
often  the  benign  hypertrophied  pylorus.  In  both  diseases 
pyloric  bubbling  may  be  felt,  and  the  pyloric  spurt  may  be 
heard,  unless  the  orifice  be  completely  obstructed. 

If  no  tumor  can  be  detected,  one  of  the  most  valuable  signs 
of  cancer  of  the  stomach  is  wanting.  This  may  happen  at 
any  stage  of  the  disease.  The  case  may  be  presented  for 
diagnosis  before  or  after  the  development  of  emaciation  and 
cachexia. 

The  diagnosis  of  carcinoma  of  the  stomach  when  no 
tumor  can  be  discovered,  and  before  nutrition  is  so  reduced  as 
to  suggest  a  serious  and  perhaps  malignant  disease,  is  a  mere 
question  of  probabilities.  But  there  are  certain  early  signs 
which  should  not  only  excite  suspicion,  but  should  cause  at 
least  a  careful  search  and  a  guarded  opinion.  And  here, 
above  all,  must  be  considered  the  age  of  the  patient,  the 
absence  of  sufficient  cause,  and  the  previous  good  digestion  of 
an  ordinary  mi.xed  diet.  If  a  person  whose  other  organs  are 
healthy,  who  is  between  forty  and  sixty  years  of  age,  who  is 
guilty  of  no  dietetic  errors  or  excesses,  without  ascrib- 
able  cause  loses  his  appetite,  feels  a  sense  of  heaviness 
or  discomfort  in  his  stomach,  at  first  during  digestion,  and 
later  when  the  organ  should  be  empty  and  at  rest,  loses 
weight  and  strength  in  spite  of  good  digestive  hygiene  and 
sufficient  food — a  suspicion  of  carcinoma  is  justifiable,  and  the 
combination  of  symptoms  and  circumstances  should  lead  to  a 
careful  search  for  otlier  signs.  The  form  which  the  emacia- 
tion takes  should  be  observed,  and  the  excessive  waste  of 
the  nitrogenous  tissues  (particularly  both  the  voluntary  and 
involuntary  muscles),  while  the  body  still  retains  a  good  deal 
of  its  fat,  should  be  carefully  noted.  The  blood  changes 
should  also  be  recorded  from  time  to  time,  and  the  number 
of  white  cells  should  be  counted  before  and  about  three 
hours  after  a  mixed  meal.  The  secretory  and  motor  func- 
tions should  be  carefully  tested,  and  the  quantity  and  char- 
acter of  the  germs  noted.  If  the  functional,  bacteriological, 
hemic,  and  nutritive  signs  become  more  and  more  like  those 
of  carcinoma,  and  in  spite  of  rational  treatment  and  a  suffi- 


THE   NEOPLASMS    OF   THE   STOMACH.  547 

cient  diet,  and  if  the  clinical  picture  remains  ill-defined  and 
characteristic  of  no  other  disease,  the  suspicion  is  probably- 
well  founded.  The  early  diagnosis  of  cancer  can  some- 
times be  made  with  a  good  deal  of  probability  by  close 
observation  and  study  of  the  case  during  two  or  three  weeks. 
The  evolution  of  the  symptoms  and  signs  in  a  particular 
manner  is  somewhat  characteristic,  and  in  this  respect  a  single 
examination  gives  little  information.  The  functional  and 
bacteriological  signs  develop  more  rapidly  in  some  cancers 
than  in  others.  The  absence  of  free  hydrochloric  acid,  the 
diminution  of  the  ferments,  the  formation  of  lactic  acid  in 
noteworthy  quantity  (i  :  1000)  in  the  thoroughly  washed 
stomach  after  a  test-meal  containing  no  lactic  acid,  motor 
insufficiency,  and  the  presence  of  lactic-acid-forming  bacilli  in 
large  numbers — may  in  themselves,  but  better  in  combination 
with  other  secondary  or  confirmatory  signs,  establish  the 
diagnosis. 

The  diagnosis  of  carcinoma  in  the  absence  of  a  palpable 
tumor,  but  after  the  development  of  the  emaciation  and 
cachexia,  can  often  be  made  if  the  functional,  bacteriological, 
hemic,  and  nutritive  signs  be  taken  in  connection  with  the 
mode  of  beginning,  with  the  evolution,  and  with  the  sub- 
jective symptoms.  These  signs  and  symptoms  need  not 
here  be  repeated,  but  great  emphasis  may  be  laid  on  their 
value  when  combined,  and  on  their  lack  of  meaning  when 
taken  singly  and  without  regard  to  their  order  of  develop- 
ment and  progressive  evolution.  Naturally,  the  anatomical 
signs,  if  obtained,  have  the  same  value  as  when  the  tumor 
can  be  detected. 

The  location  of  the  tumor  is  important  both  from  a  medi- 
cal and  a  surgical  point  of  view. 

The  tumors  of  the  pylorus  are  sometimes  very  movable, 
sometimes  disappear,  and  may  be  again  found  on  reexam- 
ination. On  inflation  of  the  stomach  they  move  downward 
and  to  the  right,  or  are  concealed  by  the  distended  pyloric 
antrum.  The  most  usual  site  of  the  tumor  is  on  or  to  the 
right  of  the  median  line,  beneath  the  loWer  border  of  the  left 
lobe  of  the  liver.  It  is  hard  and  often  annular,  and  gas  can 
be  felt  bubbling  through  it  intermittently.  Pyloric  cancer 
produces  obstructive  retention,  enlargement  of  the  stomach, 
and  often  visible,  palpable,  and  active  peristalsis. 

Cancer  of  the  cardia  is  revealed  by  the  symptoms  and  the 
signs  of  obstruction  obtained  by  the  use  of  the  sound.  The 
stomach  retracts  and  is  constantly  very  small. 


548  DISEASES  OF  THE  STOMACH. 

Tlie  tumors  of  tlie  body  of  the  stomach  may  be  located  by 
the  pliysical  signs  when  on  tlie  accessible  parts  of  the  greater 
curvature,  anterior  wall,  and  lesser  curvature.  A  tumor  of 
the  posterior  wall  may  sometimes  be  felt  when  the  stomach 
is  empty  and  the  patient  is  in  the  knee-elbow  posture ;  but  it 
disappears  when  the  stomach  is  inflated,  and  the  anterior  wall 
will  be  found  free.  A  tumor  of  the  pancreas  should  not  be 
mistaken  for  a  cancer  of  the  posterior  wall ;  the  signs  have 
already  been  given  by  which  it  can  be  determined  that  the 
tumor  is  gastric  and  malignant.  When  the  tumor  is  located 
on  the  body  of  the  stomach  and  the  pylorus  is  left  free,  the 
weight  and  strength  are  longer  maintained  and  treatment  is 
of  more  avail. 

Differential  Diagnosis. — It  often  happens  that  when  the 
patient  presents  himself  for  examination  no  tumor  can  be 
detected,  and  no  other  sign  or  symptom  is  present  which 
definitely  localizes  the  disease  in  the  stomach.  Consequently, 
when  emaciation  is  present,  carcinoma  of  the  stomach  may  be 
easily  confounded  with  Addison's  disease,  pernicious  anemia, 
forms  of  tuberculosis,  chronic  malarial  poisoning,  certain 
dynamic  affections  of  the  stomach,  di.splacements  of  the  stom- 
ach, non-malignant  obstruction  of  the  cardia  and  pylorus,  gas- 
tric ulcer,  and  chronic  gastritis.  ( For  the  differential  diagnosis 
between  cancer  of  the  stomach  and  ulcer,  anorexia  nervosa, 
nervous  vomiting,  myasthenia,  displacements  of  the  stomach, 
and  non-malignant  obstruction  of  the  cardia  and  pylorus  see 
the  articles  on  these  diseases.)  There  remains  for  considera- 
tion here  the  constitutional  cachectic  diseases  and  chronic 
asthenic  gastritis. 

Addison's  disease  is  manifested  by  the  bronzed  skin,  ex- 
treme weakness  of  the  muscular  system,  disturbances  of  the 
stomach,  and  a  form  of  emaciation  in  which  the  body  fat  may 
be  partly  conserved,  as  in  cancer.  Certain  forms  of  tuber- 
culosis run  a  slow  progressive  course  without  recognizable 
local  deposits.  Tuberculosis  is  also  common  in  cancer  of  the 
stomach.  Chronic  malarial  poisoning  may  develop  without 
chills, and  lead  in  a  number  of  months  to  pronounced  emacia- 
tion and  cachexia.  Other  particular  cases  of  chronic  disease 
develop  without  very  definite  symptoms,  and  may  resemble 
closely  the  atypical  cases  of  cancer,  which  are  not  few  in 
number.  The  differentiation  can  be  made  only  by  very  care- 
ful search  for  distinctive  signs  and  by  counting  the  probabili- 
ties. In  obscure  cases  of  suspected  tuberculosis  local  deposits 
of  the  disease  should  be  sought  in  every  part  of  the  body. 
Sometimes  the  only  detectable  local  lesion  is  tubercle  of  the 


THE   NEOPLASMS    OF   THE   STOMACH.  549 

choroid  or  a  laryngeal  or  nasal  ulcer.  The  tubercle  bacil- 
lus should  be  sought  for  in  the  urine  when  not  found  in  the 
sputum.  The  absence  of  reaction  after  the  use  of  Koch's 
tuberculin  is  decisive.  In  malarial  cachexia  the  spleen  is 
large  and  the  crescent  plasmodium  is  likely  to  be  present  in 
the  blood,  and  the  proper  study  of  the  blood  would  also  detect 
a  grave  anemia.  The  other  set  of  differential  signs  are  those 
which  are  usually  present  and  more  or  less  characteristic  of 
cancer.  Here  must  be  taken  into  consideration  all  the  sub- 
jective and  objective  signs  enumerated  in  the  description  of 
cancer  of  the  stomach,  particularly  the  functional,  bacterio- 
logical, and  anatomical  signs.  The  weighing  of  all  the  evi- 
dence accumulated  by  careful  study  may,  in  particular  cases, 
leave  room  for  doubt,  for  any  of  these  diseases  may  coexist 
with  cancer  of  the  stomach. 

Cancer  of  the  stomach  without  a  palpable  tumor  may  be 
confounded  with  chronic  gastritis,  particularly  when  the  latter 
is  accompanied  by  emaciation. 

There  are  many  features  which  differentiate  cancer  of  the 
stomach  from  the  asthenic  form  of  chronic  gastritis,  except  in 
the  very  early  stage  of  cancer,  when  the  two  diseases  may  be  so 
nearly  alike  as  to  leave  little  opportunity  for  a  plausible  guess. 
Cancer  begins  after  thirty,  often  in  persons  with  good  and 
unconscious  digestion,  suddenly  and  without  palpable  cause. 
Gastritis  begins  after  an  acute  attack  due  to  some  dietetic  or 
drinking  fault,  or  slowly  and  irregularly  in  a  stomach  which 
has  often  shown  its  weakness,  or  secondarily  to  a  disease  of 
some  other  organ.  The  subjective  symptoms  of  gastritis,  ex- 
cept the  morning  nausea  and  vomiting  of  mucus,  are  diges- 
tive. Those  of  cancer  may  be  worse  during  digestion,  but 
are  often  present  day  and  night.  The  digestive  symptoms  of 
gastritis  are  much  worse  after  solid  than  after  liquid  food,  and 
a  carefully  selected  meal  may  often  be  digested  without  dis- 
comfort. In  cancer  the  heaviness  and  fullness  recur  regu- 
larly, and  after  all  sorts  of  food.  The  appetite  in  cancer 
diminishes,  is  lost,  never  recovered,  and  often  ends  in  disgust 
for  meats  and  fats.  In  chronic  asthenic  gastritis  the  appetite 
is  irregular,  sometimes  good,  sometimes  bad,  and  often  there 
is  a  desire  for  spicy  or  sour  articles.  Vomiting  is  rare  in 
chronic  asthenic  gastritis,  and  when  present  usually  consists 
not  of  food,  but  of  a  little  mucus,  which  may  be  stained  with 
fresh  blood.  In  cancer  vomiting  is  much  more  frequent, 
alimentary,  smelling  of  organic  acids,  and  colored  like  coffee 
grounds  with  blood  which  has  been  long  in  the  stomach. 
In  chronic  asthenic  gastritis  the  hemorrhage  is  an  accident 


550  DISEASES  OF  THE  STOMACH. 

of  sounding  or  of  retching  ;  in  cancer  it  is  often  slow,  not 
due  to  traumatism,  and  is  sometimes  profuse.  Chronic 
asthenic  gastritis  is  a  painless  disease,  except  sometimes  in  its 
atrophic  stage.  Cancer  may  be  painful  during  the  period 
when  the  stomach  is  functionally  active,  and  also  when  it 
should  be  resting.  The  one  develops  slowly,  with  remissions 
and  subjective  intermissions,  without  a  tumor,  without 
cachexia,  and  without  hemorrhages  ;  the  other  progresses 
rapidly  and  continuously,  with  only  short  intervals  of  im- 
provement obtainable  by  treatment.  Chronic  asthenic  gas- 
tritis extends  through  years  without  producing  cachexia ; 
cancer  is  rapid  and  progressive  in  its  evolution.  Secretion 
diminishes  in  both,  but  free  hydrochloric  acid  may  reappear 
in  chronic  gastritis.  The  motor  function  is  long  perfectly 
maintained  in  chronic  asthenic  gastritis;  in  cancer  stagnation 
occurs,  as  a  rule,  early,  and  gastric  retention  may  not  be  long 
postponed,  even  when  the  neoplasm  is  situated  on  the  body 
of  the  organ.  Fermentation  is  an  accident  in  chronic  as- 
thenic gastritis  ;  it  occurs  very  frequently,  and  often  early,  in 
cancer,  is  chiefly  lactic,  and  accompained  by  a  characteristic 
bacillary  growth.  In  chronic  asthenic  gastritis  the  stomach 
is  empty  in  the  early  morning  before  breakfast,  or  contains 
only  a  little  fluid,  which  is  rich  in  mucus  and  chlorids,  and 
is  about  neutral  in  reaction.  In  cancer  the  stomach  often 
contains  residual  fluid  in  the  morning,  which  may  be  richer 
in  combined  HCl  than  the  filtrate  of  the  test-meal  contents  ; 
or  which  may  possess  a  high  acidity  due  to  lactic  acid,  or 
which  may  be  colored  dark  brown  by  blood.  The  anatomi- 
cal signs  may  reveal  the  presence  of  the  neoplasm,  but  a  piece 
of  the  mucous  membrane  in  the  washings  showing  only  gas- 
tritis would  not  exclude  cancer. 

Chronic  hypersthenic  gastritis  is  readily  distinguished  by 
its  irregular,  stormy,  and  intermittent  beginning,  by  the  evo- 
lution of  the  digestive  symptoms  in  relation  to  secretion  and 
to  the  quality  of  the  food,  and  by  the  invariable  presence  of 
free  HCl  after  a  test-breakfast.  The  two  diseases,  in  their 
subjective  and  objective  signs,  bear  little  resemblance,  unless, 
as  very  seldom  happens,  the  neoplasm  is  engrafted  in  an  old 
ulcer.  The  presence  of  a  tumor  is  against  gastritis,  unless  the 
gastritis  be  accompanied  by  an  ulcer.  If  the  clinical  history, 
duration,  and  evolution  do  not  differentiate  them,  the  diagno- 
sis is  left  in  doubt,  but  with  an  exceedingly  strong  presumption 
against  carcinoma.  If  ulcer  can  be  excluded,  carcinoma  goes 
with  it.     Simple  ulcer  and  chronic  hypersthenic  gastritis  may 


THE   NEOPLASMS   OF   THE   STOMACH.  55  I 

become    complicated    by    engrafted   cancer,    which    converts 
them  into  mahgnant  and  progressive  diseases. 

Prognosis. — Cancer  of  the  stomach  is  invariably  a  fatal  dis- 
ease. Life  may  be  made  more  comfortable  and  slightly  pro- 
longed by  careful  management.  Early  and  radical  operation 
may  give  the  patient  a  few  months,  or,  possibly,  one,  two,  or 
even  five  years.  The  healing  art  can  afford  only  a  little  more 
comfort  than  unaided  nature  would  give  the  hopeless  patient. 

Treatment. — The  treatment  of  carcinoma  of  the  stomach 
is  medical  and  surgical.  The  medical  treatment  is  only  pallia- 
tive, but  the  surgical  treatment  may  be  employed  not  only 
with  a  view  to  give  temporary  relief  and  to  prolong  life,  but 
also,  in  the  early  stage,  with  a  barely  possible  hope  of  a  per- 
manent cure. 

The  medical  treatment  is  hygienic,  symptomatic,  and  pro- 
tective. Every  means  should  be  employed  to  preserve  the 
strength  and  weight  and  to  diminish  the  excessive  nitroge- 
nous waste.  Physical  and  mental  rest  are  imperative,  for  the 
organism  has  little  power  for  repairing  its  losses.  Attention 
should  be  given  to  the  skin  and  to  the  nervous  system,  with 
a  view  to  maintaining  their  functions  and  vigor  by  hydro- 
therapy, pure  air,  sunshine,  and  pleasant  surroundings. 
Digestive  hygiene  is  also  useful,  and  is  briefly  comprised  in 
bodily  rest  before  and  after  meals,  in  favoring  the  stomach, 
and  in  protection  of  the  intestines. 

It  may  well  be  doubted  that  any  drug  arrests  or  influences 
beneficially  the  growth  of  the  neoplasm,  as  has  been  claimed 
for  condurango,  chlorate  of  soda  (Brissaud),  sulphate  of 
anilin  (Fay),  and  pyoktanin  (Maibaum).  Condurango  is  an 
excellent  bitter  which  may  often  be  employed  with  advan- 
tage, and  methylene-blue  in  some  cases  seems  to  be  of  value. 
The  methylene-blue  (Merck)  should  be  given  in  a  capsule  of 
three  to  five  grains  daily,  and  a  little  powdered  nutmeg 
should  be  combined  with  it  to  correct  its  slightly  irritant 
action  on  the  urinary  tract.  Marcus  Fay  claims  that  anilin 
sulphate  delays  metastasis  and  cachexia,  and  relieves  the 
pain  better  than  opium.  Given  internally,  in  one  to  five 
grains  a  day,  its  absorption  lasts  about  two  hours,  when  the 
nails  and  lips  become  blue,  and  after  several  days'  adminis- 
tration the  urine  becomes  reddish.  In  full  doses  it  produces 
vertigo,  shivering,  dyspnea,  fainting,  and  tonic  contraction  of 
the  involuntary  muscles.  None  of  these  drugs,  it  must  be 
confessed,  is  of  much  value,  except  condurango  as  a  bitter 
and  methylene-blue,  or  phenacetin,  or  codein,  or  opium  and 
belladonna  to  relieve  the  pain. 


552  DISEASES  OF  THE  STOMACH. 

But  the  medical  treatment  does  not  consist  in  the  vain 
search  for  some  specific,  nor  in  efforts  to  arouse  the 
depressed  functions  of  the  stomach.  The  treatment  of  the 
stomacli  should  be  protective  and  not  excitant,  irritation  of 
all  kinds  only  doing  harm.  But  the  maintenance  of  the 
appetite  and  of  the  motor  function  is  well  worthy  of  attention, 
and  may  be  best  accomplished  by  a  combination  of  the 
infusion  of  condurango  bark  and  hydrochloric  acid  with 
strychnin.  The  prescription  should  be  ordered  half  an  hour 
before  meals,  and  is  most  valuable  when  lactic  acid  fermen- 
tation is  present.  Hydrochloric  acid  (but  it  sometimes  is  not 
well  borne)  may  be  ordered  in  repeated  doses  during  the 
period  of  gastric  digestion. 

Pain  is  often  distressing,  and  demands  relief  When  the  pain 
is  severe,  there  should  be  no  hesitation  in  giving  codein  or 
morphin,  hypodermically  or  by  the  mouth,  after  milder  anal- 
gesics have  failed.  There  is  nothing  to  fear  from  a  possible 
opium  habit  when  the  patient  is  already  the  victim  of  a  malig- 
nant disease.  Vomiting  may  require  the  usual  efforts  to  con- 
trol it.  No  one  procedure  does  more  good  than  lavage.  A 
wet  compress,  covered  with  a  rubber  coil,  through  which  hot 
water  flows,  the  application  being  made  half  an  hour  before 
the  meal  and  kept  on  during  the  period  of  digestion,  may  be 
beneficial. 

To  control  fermentation  and  to  remove  the  products  of  re- 
tention, lavage  acts  better  than  any  other  remedy,  but  it 
should  be  employed,  when  the  disease  is  advanced  or  when 
there  is  hemorrhage,  with  the  greatest  care  or  not  at  all. 
This  is  particularly  true  when  the  neoplasm  involves  the  body 
of  the  stomach.  But  in  cancer  of  the  pylorus  and  in  infiltrating 
scirrhus  it  may  be  used  without  danger,  but  not  more  than  a 
pint  of  water  should  be  allowed  to  flow  in  before  beginning  to 
withdraw  it ;  the  danger  of  perforating  the  degenerate  wall  by 
overdistention  is  thus  avoided.  The  lavage  should  be  per- 
formed thoroughly  in  the  morning,  an  hour  before  breakfast, 
and  the  hydrochloric  acid  tonic  should  be  administered  a 
half  hour  later. 

The  diet  should  be  regulated  so  as  to  favor  the  stomach,  to 
protect  the  intestines,  and  to  maintain  nutrition  as  long  as 
possible.  An  exclusive  or  reducing  diet  in  this  disease  is 
radically  wrong,  and  the  food  selected  should  not  excite  or 
irritate  the  stomach,  remain  long  in  it,  easily  ferment,  or  be 
indigestible  by  the  intestines.  Milk  seldom  agrees  well, 
except  in  the  early  stage  of  some  cases  where  stagnation  and 
fermentation  are  slight.     In  the  stage  of  gastric  retention  it 


THE   NEOPLASMS   OF   THE   STOMACH.  553 

only  adds  fuel  to  the  flame.  Consequently,  finely-divided 
tender  meats,  lean  fresh  fish,  and  white  of  egg  must  usually  be 
depended  upon  to  furnish  the  nitrogenous  needs  of  the  body, 
but  should  not  be  given  in  excess  with  the  vain  hope  of  cov- 
ering the  excessive  nitrogenous  waste.  Fat,  in  the  form  of 
fresh  butter  or  a  good  emulsion  of  cod-liver  oil,  is  valuable  and 
digestible  in  moderate  quantity.  Meat  juice  and  clear  vege- 
table soups  maybe  prescribed  in  order  to  furnish  the  requisite 
quantity  of  salts.  Meat  jellies  often  agree  well  and  supplant 
the  sweets,  which  must  be  excluded.  Very  thoroughly 
cooked  whole  wheat,  with  all  the  bran  removed,  and  purees  of 
vegetables  digestible  by  the  intestines  usually  agree  well  when 
the  stomach  is  kept  clean  by  lavage  and  the  hydrochloric  acid 
tonic  is  given.  Supplementary  rectal  feeding  should  be  em- 
ployed early,  and  not  held  back  as  a  last  resort,  when  it  is  too 
late  to  be  of  much  value.  Alone,  it  exerts  little  influence  on 
the  progressive  inanition  of  carcinoma. 

The  surgical  treatment  is  palliative  and  prolongs  life.  In 
cancer  of  the  cardia  gastrostomy  should  be  performed  as  soon 
as  the  patient  is  no  longer  able  to  swallow  enough  food  to 
nourish  the  body.  An  attempt  to  dilate  the  obstructed  cardia 
by  means  of  esophageal  sounds  or  dilators  is  more  likely  to 
be  injurious  than  beneficial,  on  account  of  the  swelling  and  in- 
flammation excited  and  the  danger  of  perforation.  Little 
can  be  said  in  favor  of  the  esophageal  cannula.  Where  reten- 
tion occurs  above  the  obstruction,  the  constant  irritation  causes 
the  neoplasm  to  grow  more  rapidly,  and  gastrostomy  might  be 
performed  early  in  order  to  avoid  this  effect.  But,  as  a  rule, 
gastrostomy  should  not  be  performed  while  the  body  can  be 
nourished  by  combined  oral  and  rectal  feeding. 

The  most  frequent  operation  for  cancer  of  the  body  of  the 
stomach  and  of  the  pylorus  is  gastro-enterostomy.  This  is 
only  a  palliative  operation,  which  improves  the  motor  function 
without  perceptibly  increasing  secretion.  The  operation  is 
often  followed  by  a  remarkable  improvement  in  nutrition, 
and  by  the  subsidence  of  the  inflammatory  swelling  around 
the  neoplasm.  It  is  the  best  palliative  operation,  and  should 
be  performed  when  retention  renders  it  no  longer  possible  to 
sufficiently  nourish  the  suffering  patient. 

Pylorectomy  is  an  effort  to  produce  a  radical  cure,  but  thus 
far  it  has  failed.  It  is  the  preferable  operation  when  the  neo- 
plasm is  pyloric,  without  adhesions,  enlarged  glands,  or 
metastasis,  and  when  the  operation  can  be  done  in  sound 
tissue  wide  of  the   zone  of  extension.      In  suitable  cases  a 


554  DISEASES  OE  T//E  STOMACH. 

respite  is  obtained   until  tlie  tumor  recurs,  and  gastro-enter- 
ostoniy  may  be  done  after  the  recurrence,  to  prolong  life. 

The  mortality  of  pylorectomy  for  cancer  varies  from  55 
to  27  per  cent.  Wlicn  adhesions  and  complications  exist, 
the  mortality  is  much  higher  (60  per  cent.)  than  in  properly 
operable  cases  (25  per  cent.).  The  reports  of  Billroth's  clinic 
from  1 880  to  1 894 (Hacker)  give  19  deaths  in  42  operations;  but 
only  4  of  the  last  16  cases  died.  The  mortality  of  pylorectomy 
done  by  e.xperienced  surgeons  does  not  differ  materially  from 
that  of  gastro-enterostomy.  The  latter  operation  appears  to 
give  greater  immediate  relief;  and,  with  very  few  e.xceptions, 
the  patients  have  lived  as  long  after  it  as  after  pylorectomy. 
Kocher,  Czerny,  and  Ratimmow  report  cases  in  good  health 
from  four  to  eight  years  after  pylorectomy.  No  radical  cure 
has  been  obtained  in  Billroth's  clinic,  although  one  patient 
lived  more  than  five  years. 


CHAPTER  IV. 
THE   DISPLACEMENTS   OF   THE   STOMACH. 

Transposition  of  the  stomach  is  a  very  rare  condition,  and 
one  which  can  easily  be  discovered  on  physical  examination. 
The  fundus  is  transposed  to  the  right,  and  the  pylorus  lies  in 
the  left  hypochondrium.  The  other  parts  of  the  digestive 
tube  and  its  accessory  glands  are  correspondingly  changed 
in  position.  This  is  an  anomaly  of  development,  not  a  dis- 
ease, and  requires  no  further  mention. 

The  pathological  displacements  of  the  stomach,  particularly 
frequent  in  women,  are  very  numerous  in  their  anatomical 
details.  But  all  of  them  are  deviations  from  the  three  grand 
clinical  types — upward  displacement,  lateral  displacement,  and 
total  descent. 

The  abdominal  cavity,  formed  in  part  by  pliable  walls,  is 
subject  to  the  action  of  atmospheric  and  other  external  pres- 
sure, and  the  organs  and  viscera  contained  within  it  readily 
change  their  form.  The  stomach  is  attached  by  ligaments  to 
the  liver,  spleen,  diaphragm,  and  transverse  colon,  and  is  con- 
tinuous with  the  esophagus  and  duodenum.  Consequently, 
the  displacements  of  the  stomach  are  accompanied  by  changes 
in  the  form  of  the  abdomen  and  in  the  form  and  relative  posi- 
tion of  neighboring  organs.     Its  attachments,  also,  are  ren- 


THE   DISPLACEMENTS   OF   THE   STOMACH.  555 

dered  lax  or  are  stretched,  tnus  causing  displacements  of  at- 
tached organs  and  disordering  the  blood-  and  lymph-circula- 
tion. These  results  often  interfere  with  the  nutrition  of  its 
coats  and  with  its  functions.  The  interference  with  nutrition 
by  compression  and  by  traction  maybe  localized  and  circum- 
scribed, and  a  strong  predisposition  to  ulcer  may  thus  be 
created.  The  new  relations  produce  new  points  of  contact 
and  new  directions  of  least  resistance,  and  consequently  the 
viscus  is  liable  to  undergo  particular  changes  in  form.  The 
churning  and  evacuation  of  its  contents  must  be  done  in  un- 
usual and  unfavorable  circumstances.  The  evacuation  of  the 
stomach  may  be  specially  difficult  on  account  of  the  traction 
brought  to  bear  on  the  beginning  of  the  duodenum  and  the 
pyloric  region,  and  on  account  of  the  constriction  of  the  duo- 
denum at  its  first  point  of  firm  attachment.  The  necessity 
for  increased  work  at  a  mechanical  disadvantage  entails  either 
compensatory  hypertrophy  of  the  muscular  layer  or  motor 
insufficiency.  The  clinical  forms  of  displacement  are  three  in 
number — upward,  lateral,  and  downward. 

I.  Upward  Displacement — The  upward  displacement  of 
the  stomach  can  occur  only  in  the  left  concavity  of  the 
diaphragm.  The  part  of  the  stomach  to  the  right  of  the 
cardia  can  not  be  displaced  upward,  for  the  organs  above  it 
are  solid  and  fixed.  The  upward  displacement  of  the  stom- 
ach is  less  frequent  than  the  other  forms  of  displacement, 
but  it  occurs  much  more  frequently  than  is  generally 
recognized. 

Etiology. — The  fundus  of  the  stomach  may  be  situated 
abnormally  high  when  the  left  lung  is  collapsed  (atelectasis, 
sequel  of  left  pleurisy),  or  the  stomach  may  be  forced 
upward  by  a  large  abdominal  tumor.  But  the  most  frequent 
cause  of  this  form  of  displacement  is  compression  and 
arrested  development  of  the  trunk  on  a  line  which  runs 
across  the  abdomen  near  the  umbilicus  and  below  the  liver, 
the  splenic  flexure  of  the  colon,  and  the  spleen.  The  costal 
arch  is  slightly  narrowed,  and  the  lower  four  or  five  ribs  are 
forced  far  inward,  so  as  to  make  the  smallest  part  of  the 
waist  nearly  on  a  line  with  the  iliac  crests. 

Clinical  Description. — Upward  displacement  of  the  stomach 
may  be  a  latent  disease,  or,  at  least,  only  insignificant  sub- 
jective symptoms  may  result  from  it ;  but  in  some  cases  the 
distress  occurs  in  paroxysms,  and  in  others  the  disturbances 
are  persistent.  The  symptoms  vary  greatly,  and  bear  a 
relation  to  the  manner  in  which  the  displacement  has  been 
produced.    There  may  be  only  a  slight  sense  of  fullness  in  the 


55^  DISEASES  OF   THE   STOMACH. 

left  hypochondrium  after  meals,  or  great  difficulty  may  be 
experienced  in  vomiting,  in  belching,  or  in  eructation,  the 
cardia  being  drawn  upward  and  to  the  left  and  the  esophagus 
being  obstructed  at  its  point  of  passage  through  the 
diaphragm  so  as  to  prevent  the  exit  of  the  contents  of  the 
stomach.  The  upward  displacement  of  the  fundus  and  its 
distention  with  gas  may  produce  shortness  of  breath, 
palpitations,  arrhythmia,  left  intercostal  neuralgia,  and  pre- 
cordial pain.  These  symptoms  may  occur  in  paroxysms 
after  eating  and  after  exertion  during  the  digestive  period, 
but  are  most  frequent  in  the  evening  after  the  chief  meal  of 
the  day.  When  the  displacement  results  from  the  creation  of 
the  long  and  low  waist,  the  same  gastric  symptoms  may  be 
present,  but  to  these  are  added  symptoms  due  to  the  dis- 
placement and  to  compression  of  the  colon  ;  the  transverse 
colon  is  shortened  and  falls  into  a  V-shape,  the  splenic 
flexure  is  made  more  acute,  the  hepatic  flexure  is  prolapsed 
or  forced  inward,  and  the  colon  is  compressed  against  the 
spinal  column  and  by  the  tips  and  borders  of  the  ribs. 
There  results  from  this  compression  and  deformity  a  series  of 
troubles — constipation,  stagnation,  ulceration,  pseudomem- 
branous formation,  points  of  peritonitis,  together  with  all 
their  local  and  general  effects. 

Objective  Signs. — In  upward  displacement  of  the  stomach 
there  may  be  but  little  alteration  of  the  position  of  the  greater 
curvature;  but,  as  a  rule,  only  the  pyloric  end  of  the  stomach 
lies  in  the  epigastrium,  the  pylorus  being  displaced  trans- 
versely to  the  left,  and  the  greater  curvature  lying  so  high  as 
to  create  the  impression  that  the  stomach  is  abnormally  small. 
Gastric  tapping-splashing  can  not  be  elicited  for  the  reason 
that  so  little  of  the  stomach  lies  in  the  epigastrium.  On  per- 
cussion, the  superior  border  of  the  fundus  is  abnormally  high, 
and,  usually,  abnormally  broad;  and  these  abnormalities  exist 
when  the  stomach  is  only  moderately  distended  with  air  or 
gas.  It  is  often  possible  to  produce  succussion  splashing,  and 
the  location  of  the  sound  will  roughly  reveal  the  situation 
of  the  stomach,  which  may  be  determined  with  precision  by 
percussion  after  inflation  and  after  filling  the  stomach  with 
water,  and  by  electric  illumination.  The  heart  is  sometimes 
displaced  to  the  right  by  the  distended  fundus. 

Treatment. — The  treatment  comprises  the  removal  of  the 
cause  so  far  as  possible;  the  prevention  of  the  accumulation 
of  a  large  quantity  of  gas  in  the  stomach  ;  the  avoidance  of 
heavy  meals  ;  and  rest,  with  the  clothing  loosened,  during  the 
period  of  digestion.     The  alkaline  carbonates  and  effervescing 


THE   DISPLACEMENTS    OF   THE   STOMACH.  557 

drinks  do  harm,  and  the  diet  and  medication  should  be  so 
ordered  as  to  obtain  rapid  evacuation  of  the  stomach  and  to 
prevent  spasm  of  the  pylorus.  The  severe  respiratory  and 
cardiac  paroxysms  are  relieved,  as  if  by  magic,  by  the  with- 
drawal of  the  gas  from  the  stomach  by  means  of  the  stomach- 
tube.  Antispasmodics  and  carminatives  are  far  more  valuable 
than  stimulants  and  anodynes.  Digitalis,  strophanthus,  and 
similar  heart  stimulants  increase  the  palpitation  and  the 
arrhythmia.  The  increase  of  abdominal  tension  should  be 
avoided,  and  intestinal  flatulency  should  be  controlled. 

2.  Vertical  or  Lateral  Displacement. — In  vertical  displace- 
ment of  the  stomach  the  position  of  the  cardia  and  of  the 
line  marking  the  superior  border  remains  as  in  health.  The 
part  of  the  stomach  in  the  left  concavity  of  the  diaphragm, 
and  above  a  plane  cutting  across  the  body  on  a  level  with  the 
cardiac  orifice,  is  unchanged  in  its  form  and  position.  The 
changes  characteristic  of  vertical  displacement  occur  below 
this  line.  The  greater  curvature  is  displaced  downward  to  the 
left,  cutting  the  costal  border  near  the  tip  of  the  tenth  car- 
tilage. The  lesser  curvature  becomes  straighter  or  is  bent 
near  its  middle  into  almost  a  right  angle,  accordingly  as  the 
pylorus  is  more  or  less  displaced.  The  anterior  and  posterior 
surfaces  of  the  stomach  face  more  directly  forward  and  back- 
ward. The  axis  of  the  pyloric  end  runs  transversely,  or 
downward  toward  the  right  iliac  fossa,  or  more  directly 
upward,  the  variation  corresponding  with  the  particular  form 
which  the  stomach  takes.  The  greater  part  of  the  grand  axis 
of  the  stomach  is  almost  vertical.  The  relations  of  the  stomach 
are  changed  and  its  form  is  greatly  modified,  particularly  the 
transverse  diameter.  Such  are  the  general  characters  of  ver- 
tical displacement.  The  special  anatomical  forms  will  be 
more  minutely  described  in  the  paragraphs  on  the  pathological 
anatomy,  and  should  be  carefully  studied,  with  a  view  to  facili- 
tating the  solution  of  many  of  the  puzzles  of  difTerential 
diagnosis. 

Etiology. — Vertical  displacement  of  the  stomach  is  rare  in 
men  but  quite  frequent  in  women,  who  seem  compelled  by 
fashion  to  deform  their  waists  in  slavery  to  a  false  conception 
of  the  beautiful.  The  disease  may  be  a  legacy  of  infancy  or 
of  fetal  life,  the  stomach  remaining  in  the  position  in  which 
it  was  held  by  the  relatively  and  excessively  large  liver  of  this 
period.  The  stomach  may  also  be  vertically  displaced  by  en- 
largement and  tumors  of  the  liver,  and  by  other  tumors  and 
by  pus  collections  to  the  right  of  the  lesser  curvature  ;  but 
by  far  the  most  common  cause  is  the  corset.     In  the  verti- 


558  DISEASES  OF  THE  STOMACH. 

cal  displacement  produced  by  the  corset  the  line  of  greatest 
compression  runs  across  the  liver,  the  first  portion  of  the  duo- 
denum, the  pylorus,  and  the  spleen.  The  costal  arch  is  very 
narrow,  but  the  base  of  the  arch  may  be  broad  and  the  costal 
borders  curved  outward  and  forward.  The  surface  of  the 
liver  is  grooved  by  the  ribs,  and  the  gland  is  compressed  from 
side  to  side  and  elongated  downward.  The  pylorus  is 
obstructed  by  the  compression,  as  are  likewise  the  duodenum 
and  the  cystic  and  common  ducts.  The  pyloric  end  of  the 
stomach  dilates  downward  below  the  constriction,  and  the 
stomach  may  be  made  bilocular,  the  area  of  constriction  pass- 
ing between  the  spleen,  the  depressed  ribs,  the  left  lobe  of  the 
liver,  and  the  vertebral  column. 

Genesis  and  Pathological  Anatomy. — The  principal  parts  in 
the  development  of  vertical  displacement  of  the  stomach  are 
played  by  the  left  lobe  of  the  liver  and  by  the  constriction  of 
the  waist  in  a  particular  manner.  The  compression  of  a  tight 
corset  worn  during  the  period  of  puberty  arrests  the  develop- 
ment of  the  constricted  part  of  the  body.  All  the  diameters 
of  the  abdominal  cavit\' throughout  the  compressed  region  are 
shortened  and  their  increase  during  the  period  of  develop- 
ment is  prevented.  The  compression  of  the  corset,  however, 
differs  from  that  of  a  cord  or  a  narrow  band,  and  extends 
from  near  the  cartilages  of  the  eighth  ribs  to  within  a  short 
distance  of  the  breasts.  The  costal  arch  is  narrowed,  ex- 
cept near  the  base,  where  the  costal  border  curves  rapidly 
outward  and  forward.  The  results  of  the  cylindrical  com- 
pression are  displacement  and  deformity  of  the  organs 
brought  within  its  influence.  As  there  can  be  no  lateral 
expansion,  the  respiratory  movements  of  the  organs  of  the 
abdomen  are  directly  up  and  down.  The  solid  organs,  such 
as  the  liver,  push  what  is  movable  before  them,  and  the  de- 
forming pressure  of  the  liver  and  the  distention  of  the  gastric 
wall  occur  downward,  in  the  direction  of  least  resistance. 
The  fundus  of  the  stomach  is  above  the  area  of  compression  ; 
but  lower  down,  the  costal  wall,  the  spleen,  the  liver,  and  the 
stomach  bear  the  brunt  of  the  pressure.  It  is  here  nearly 
on  a  level  with  the  ensiform  process  that  the  waist  is  smallest, 
and  the  liver  is  often  marked  by  a  furrow  running  across  its 
anterior  surface.  The  stomach  yields  its  place  to  the  solid 
liver,  there  being  only  sufficient  room  (provided  the  corset 
has  been  put  on  early  in  life  and  worn  tight)  between  the 
anterior  abdominal  wall  and  the  vertebral  column  for  the  left 
lobe  of  the  liver  and  the  pancreas.  The  lesser  curvature  of 
the   stomach,   which   is    compressed   between    the   li\'er,  the 


THE   DISPLACEMENTS   OF   THE   STOMACH.  559 

spleen,  and  the  ribs,  is  forced  to  the  left  and  downward,  and 
runs  along  the  border  of  the  left  lobe.  If  the  spleen  and 
liver  be  enlarged,  the  compressed  part  of  the  stomach  may  be 
reduced  to  the  size  of  the  small  intestine.  Nearly  the  whole 
of  the  deformed  stomach  thus  lies  vertically  displaced  to  the 
left  of  the  left  parasternal  line,  and  it  may  be  bilocular. 

There  are  three  typical  anatomical  forms  of  vertical  dis- 
placement of  the  stomach — the  angular,  the  fish-hook,  and 
the  straight. 

The  angular  fonn  is  quite  common,  and  is  the  result  chiefly 
of  the  form  and  size  of  the  left  lobe  of  the  liver.  The  lesser 
curvature,  and  with  it  the  body  of  the  stomach,  are  displaced 
outward  to  the  left  and  into  the  left  hypochondrium.  The 
pylorus  is  about  on  a  level  with  the  junction  of  the  middle  and 
lower  thirds  of  the  line  joining  the  umbilicus  and  the  xiphoid 
process,  either  on  the  median  line  or  about  an  inch  to  the  left 
of  it.  The  pyloric  end,  forming  one  side  of  the  angle,  runs 
transversely  across  the  abdomen  and  close  along  the  lower 
border  of  the  left  lobe  of  the  liver,  by  which  it  is  not  cov- 
ered. The  pancreas  may  form  the  limiting  and  fixing  upper 
wall,  the  left  lobe  being  a  little  higher  up,  with  its  lower  border 
curved  backward  on  a  transverse  axis.  At  the  point  where 
the  stomach  passes  beneath  the  left  costal  border  a  constriction 
often  exists,  which  is  yielding  and  not  cicatricial.  The  greater 
curvature  passes  the  costal  border  low  down  and  far  to  the  left. 
Along  and  partly  covered  by  the  costal  border  often  lies  the 
distended  and  most  capacious  part  of  the  deformed  stomach. 
The  other  side  of  the  angle,  represented  by  the  remainder  of 
the  long  axis  of  the  stomach,  passes  vertically  through  the 
left  hypochondrium.  The  angle,  instead  of  being  sharply 
formed,  is  sometimes  cut  off  by  a  short  curve. 

1\\e  Jish-hook  variety  is  a  very  serious  form  of  displacement. 
The  pylorus  usually  remains  in  its  normal  position,  but  the 
orifice  faces  almost  directly  upward.  The  pyloric  extremity  of 
the  stomach  rises  almost  vertically  over  the  head  of  the  pan- 
creas, and  is  continuous  with  the  duodenum,  which  runs  up- 
ward and  to  the  right,  joins  its  fixed  part  at  an  angle,  and  pro- 
duces a  constricting  kink.  The  lesser  curvature  runs  below 
both  the  left  lobe  of  the  liver  and  all  the  pancreas  but  the  head. 
The  greater  curvature  sweeps  by  the  navel  and  passes  under 
the  costal  border  near  the  tip  of  the  tenth  rib.  This  curved 
part  of  the  hook  is  often  dilated,  and  the  greater  curvature 
may  extend  downward  and  to  the  right  across  the  median 
line.  The  sharp  convexity  of  the  dilated  pyloric  part  points 
to    the    right   iliac    fossa.       On    account    of    this    particular 


560  DISEASES  OF  THE  STOMACH. 

form  of  the  stomach  its  muscle  works  at  a  great  disad- 
vantage in  its  efforts  to  overcome  the  obstruction  in  the 
duodenum.  The  vertical  part  of  the  stomach,  pushed  far 
into  the  left  hypochondrium,  is  often  compressed  between  the 
overlapping  lett  lobe  of  the  liver  and  the  spleen,  and  the 
transverse  diameter  of  the  stomach  at  the  point  of  com- 
pression may  be  reduced  to  i '<  or  two  inches. 

In  the  straight  forjfi  the  duodenohepatic  ligament  is  elon- 
gated, and  the  pj'lorus  lies  very  close  to  the  umbilicus.  The 
lesser  curvature  bends  slightly  on  its  way  to  the  cardia.  Nearly 
the  whole  of  the  long  axis  of  the  stomach  is  vertical,  and  the 
body  of  the  organ,  on  account  of  the  particular  deformity  of 
the  liver  which  causes  the  displacement,  is  usually  but  slightly 
compressed.     This  is  the  least  frequent  of  the  three  varieties. 

The  vertically  displaced  stomach  may  descend  in  the  abdo- 
men, and  the  upper  limit  of  the  fundus  may  be  lowered. 
Associated  with  vertical  displacement  of  the  stomach  are 
deformities  and  displacements  of  other  abdominal  organs. 
The  liver  rotates  on  a  transverse  axis,  or  descends  in  the  abdo- 
men, or  is  pressed  out  of  its  normal  shape.  The  right  kidney 
is  more  or  less  movable.  The  spleen  is  displaced  and  de- 
formed. There  may  be  splanchnoptosis  or  enteroptosis,  par- 
ticularly if  the  abdominal  wall  is  flabby. 

Clinical  Description. — Vertical  displacement  may  exist  with- 
out producing  a  local  or  general  subjective  symptom.  It  is  a 
disease  which  is  often  without  an  expression.  From  puberty 
to  old  age  digestion  may  be  good  and  the  general  health 
e.Kcellent.  This  latency  constitutes  its  seemingh'  harmless 
nature  and  also  its  serious  danger.  A  vertically  displaced 
stomach  is  a  constant  menace  to  health. 

There  can  be  no  doubt  that  a  vertically  displaced  stomach 
does  its  work  at  a  great  disadvantage,  and  the  motor  func- 
tion upon  the  integrity  of  which  health  depends  may  easily 
become  insufficient.  The  organ  is  in  a  state  of  unstable 
equilibrium. 

One  class  of  subjective  symptoms  is  due,  not  to  the  dis- 
placement of  the  stomach  alone,  but  to  the  combined  effect  of 
the  changed  relations  and  deformities  of  the  abdominal 
organs.  There  is  sometimes  localized  peritonitis,  traumatic 
in  its  genesis.  This  is  manifested  by  local  pain  and  tender- 
ness, and  by  constitutional  depression,  most  often  mistaken 
for  visceral  neuralgia.  The  sympathetic  nerves  are  irritated 
by  being  stretched  and  compressed,  often  producing  local  dis- 
comfort, which  is  most  marked  after  walking  and  jolting  exer- 
cise ;  and  dragging  sensations  may  be  experienced  about  the 


THE   DISPLACEMENTS    OF   THE   STOMACH.  56 1 

loins.  The  abdominal  sympathetic  nerve  may  be  so  irritated 
as  to  cause  neurasthenic  symptoms.  Neurasthenia  is  a  com- 
mon expression  of  a  developing  or  unsuspected  displacement 
of  the  abdominal  organs,  including  vertical  displacement  of 
the  stomach. 

But  the  displacement  and  the  constriction  that  caused  it 
do  more :  the  blood-  and  lymph-circulations  are  disordered. 
The  blood-vessels  running  in  the  folds  of  the  ligaments  are 
stretched,  compressed,  and  distorted,  here  producing  stasis, 
there  causing  anemia.  Furthermore,  the  intra-abdominal 
tension  is  modified,  and  the  beneficial  effect  of  respiration 
on  the  circulation  of  the  abdomen,  particularly  that  of  the 
lymph,  is  diminished.  The  result  is  that  these  patients  often 
emaciate,  age  early,  become  anemic,  lose  energy,  and  are 
morose,  melanchoHc,  and  sometimes  irritable.  This  change 
of  character  and  disposition  is  often  a  revealing  sign.  The 
characteristics  of  the  anemias  produced  by  the  displacements 
of  the  stomach  are  that  they  are  rebellious  to  treatment,  are 
not  much  benefited  by  iron  or  arsenic,  but  are  cured  by  rest 
in  bed  and  proper  alimentation;  and  this  is  likewise  true  of 
the  neuralgic,  neurasthenic,  and  psychic  symptoms  produced 
by  the  disturbed  equilibrium  of  the  abdomen. 

The  fish-hook  form  of  vertical  displacement  may,  as  has 
already  been  stated,  produce  duodenal  obstruction.  The 
symptoms  are,  then,  those  of  the  stages  of  compensation, 
stagnation,  or  retention,  as  described  under  pyloric  obstruc- 
tion ;  but  the  distinctive  sign  is  the  discovery  of  a  stomach 
vertically  displaced  and  assuming  this  particular  form.  A 
constant  danger  of  the  vertically  displaced  stomach  is  motor 
insufficiency. 

Objective  Signs. — The  physical  signs  are  characteristic,  for 
they  reveal  the  particular  form  and  position  of  the  stomach 
which  constitute  the  disease.  An  important  and  suggestive 
sign  furnished  by  inspection  is  the  corset-waist.  The 
costal  borders  are  compressed,  and  just  below  the  ensiform 
process  is  the  junction  of  the  two  cones,  with  their  bases 
facing  up  and  down,  the  patient  being  viewed  from  in  front. 
The  lower  costal  borders  are  somewhat  everted.  The  arch 
formed  by  the  costal  borders  is  narrowed,  the  upper  por- 
tion of  both  borders  approaching  nearer  to  the  median  line. 
The  epigastrium  is  flat,  and  the  lower  part  of  the  abdomen  is 
prominent.  The  lateral  expansion  and  development  of  the 
cavity  inclosed  by  the  false  ribs  have  been  arrested.  Natur- 
ally, this  suggestive  form  of  the  abdomen  is  lacking  when  the 
displacement  of  the  stomach  has  been  caused  by  enlargement 
36 


562  DISEASES  OF  77/ E  STOMACH. 

of  the  left  lobe  of  the  liver  or  by  tumors  of  the  right   hypo- 
chondrium. 

More  conclusive  are  the  signs  which  reveal  the  form  and 
position  of  the  stomach.  The  abdomen  should  first  be  exam- 
ined when  the  stomach  is  empty.  The  organ  is  next  inflated. 
It  will  first  be  noted  that  the  epigastrium  has  not  been  dis- 
tended by  this  procedure,  but  retains  its  flat  form.  If  the 
abdominal  wall  is  lax,  the  small  portion  of  the  stomach  un- 
covered by  the  left  ribs  may  be  seen  outlined  as  a  prominent 
ridge.  On  percussion,  the  upper  limit  of  the  fundus  of  the 
stomach  will  be  found  in  its  normal  position,  and  the  greater 
tuberosity  will  reach  as  high  as  the  fifth  interspace.  The 
line  of  the  greater  curvature  runs  far  to  the  left,  emerges  from 
under  the  ribs  near  the  cartilage  of  the  tenth  rib  or  a  little 
higher,  and  ends  at  the  pylorus,  which  may  be  on  the  median 
line,  to  the  left  or  the  right  of  it,  or  in  its  normal  position, 
as  described  under  the  pathological  anatomy.  The  lesser 
curvature  is  displaced  downward  and  to  the  left,  and  is 
located  by  inspection,  palpation,  and  percussion  along  the 
border  of  the  left  lobe  of  the  liver.  In  the  median  line  of  the 
epigastrium  only  the  left  lobe  of  the  liver  and  the  pancreas 
are  interposed  between  the  anterior  abdominal  wall  and  the 
spinal  column.  The  aorta  can  here  be  easily  felt,  and  its  pul- 
sation is  often  visible.  A  glass  of  water  should  next  be  ad- 
ministered, and  by  the  aid  of  the  splashing  sounds  confirma- 
tory evidence  of  the  position  and  form  of  the  stomach  can  be 
obtained.  The  water  and  gas  can  often  be  felt  and  heard 
bubbling  through  the  pylorus.  The  position  of  the  curvature 
and  of  the  pylorus  reveals  the  angular,  fish-hook,  and  straight 
varieties  of  vertical  displacement. 

It  will  be  noted  that  the  transverse  diameter  of  the  stomach 
near  the  level  of  the  lower  border  of  the  left  lobe  of  the  liver 
is  very  small.  The  stomach  also  extends  low  down  in  the 
abdomen,  and  a  great  part  of  it  lies  in  the  left  hypochon- 
drium.  On  account  of  its  position  and  form  and  the  lines  of 
compression,  respiratory  gurgling  is  often  produced  when 
the  organ  contains  fluid  and  air.  This  symptom  is  a  shock 
to  moclesty,  and  may  be  arrested  by  changing  the  position  of 
the  body,  by  making  the  respirations  shallow,  by  loosening  or 
tightening  the  clothing,  or  by  compressing  and  lifting  the  left 
side  of  the  abdomen.  The  noise  is  produced  by  the  forced 
passage  of  fluid  and  gas  from  one  pouch  of  the  stomach  into 
another  one  separated  from  it  by  a  constriction.  The  con- 
striction is  often  produced  by  the  border  of  the  ribs  and  by 
the   colon,  while    pressure   is   made   alternately  on   the  two 


THE  DISPLACEMENTS   OF   THE   STOMACH.  563 

pouches  by  the  up-and-down  movements  of  the  stomach 
during  respiration.  This  sign  is  most  common  in  vertical 
displacement  of  the  stomach,  but  is  not  pathognomonic. 

There  are  no  abnormal  functional  signs  of  vertical  displace- 
ment of  the  stomach.  In  only  one  variety — the  fish-hook 
deformity — is  the  evacuation  of  the  stomach  interfered  with, 
and  motor  compensation  may  be  perfectly  established.  In 
many  cases  of  vertical  displacement  it  is  impossible  for  the 
patient  voluntarily  to  belch  or  to  vomit.  The  desire  may  be 
imperative,  but  the  effort  to  do  either  is  often  a  failure. 

The  abnormal  functional  and  bacteriological  signs  found  in 
vertical  displacement  of  the  stomach  are  due  to  complica- 
tions. The  most  frequent  of  these  complications  are  myas- 
thenia and  gastritis. 

Prognosis. — The  vertically  displaced  stomach,  though 
working  at  a  disadvantage,  often  performs  its  work  well. 
With  proper  digestive  hygiene  the  patient  may  go  through 
life  without  digestive  trouble.  But  it  constitutes  a  weakness, 
a  predisposition  to  disease,  and  a  danger.  When  it  exists,  the 
stomach  is  more  liable  to  disease,  and  the  cure  of  such  en- 
grafted disease  is  rendered  difficult. 

Treatment. — Much  can  be  done  in  the  prevention  of  dis- 
placement of  the  stomach  by  protection  of  the  waist  against 
undue  compression.  Custom  intervenes  at  an  early  age  and 
enforces  the  arrest  of  the  natural  development  of  this  part 
of  the  female  body.  No  great  harm  need  be  done  if  the  lacing 
be  held  within  limits.  A  corset  which  is  of  the  proper  size 
can  be  fastened  during  gastric  digestion  at  the  end  of  an 
ordinary  expiration  without  drawing  on  either  side,  and  is 
harmless  when  this  rule  is  followed  from  youth.  This  matter 
should  receive  the  personal  attention  of  mothers  who  value 
the  health  and  beauty  of  their  daughters  more  highly  than  an 
unnaturally  small  waist.  The  skirts  should  be  supported 
from  the  shoulders,  and  the  corset  and  clothing  should  never 
be  pushed  down  after  fastening,  with  a  view  to  lengthening 
the  waist. 

After  the  displacement  is  produced,  the  excessive  con- 
striction of  the  waist  should  be  removed,  and  combined  arm 
and  breathing  exercises  prescribed  in  order  to  widen  the 
costal  arch  and  to  develop  more  space  in  the  epigastrium. 
The  abdominal  muscles  should  be  strengthened  by  exercises, 
massage,  and  faradism,  and  the  lower  abdomen  should  be 
snugly  supported  by  a  bandage.  The  abdominal  support 
should  always  be  tightened  from  below   upward  before  the 


564  DISEASES  OF  THE  STOMACH. 

corset  is  put  on,  and,  in  severe  cases,  while  the  patient  is  in 
the  knee-chest  posture. 

The  treatment  of  a  complicating  disease  is  the  same  as 
when  the  stomach  is  in  its  normal  position.  But  if  myas- 
thenia and  the  secondary  anemia  require  a  remedy  in  addition 
to  those  ordinarily  employed,  rest  in  bed  should  be  pre- 
scribed. In  the  mild  form  of  myasthenia  and  in  mild 
anemia  the  patient  should  recline,  with  the  clothing  loosened, 
during  the  greater  part  of  the  period  of  gastric  digestion.  In 
the  severe  form  of  myasthenia  with  stagnation,  in  myasthenia 
with  retention,  and  in  advanced  and  grave  anemia,  a  methodi- 
cal cure  with  uninterrupted  rest  in  bed  should   be  employed. 

3.  Qastroptosis,  or  Total  Descent  of  the  Stomach. — Gas- 
troptosis  is  the  most  frequent  displacement  of  the  stomach, 
and  is  usually  associated  with  the  displacement  of  other 
abdominal  organs.  The  whole  stomach  is  prolapsed,  and  lies 
nearly  transversely  in  the  abdominal  cavity.  The  pylorus 
may  remain  near  its  normal  position,  but  it  is  commonly 
lower  down.  The  horizontal  part  of  the  duodenum  is  the  first 
fixed  point,  and  it  is  here  that  angular  obstruction  is  likely  to 
occur.  The  cardia  also  descends  and  lies  on  a  level  with  the 
body  of  the  twelfth  dorsal  vertebra.  The  fundus  of  the 
inflated  stomach  is  below  the  fifth  rib,  and  the  lesser  curvature 
runs  across  the  abdomen  in  the  lower  half  of  the  line  joining 
the  umbilicus  and  the  ensiform  process.  The  point  where 
the  greater  curvature  crosses  the  costal  border  is  further  down 
and  further  to  the  left  than  it  is  normally  located,  and  the  lower 
limit  of  the  stomach  runs  across  the  abdomen  and  the  median 
line  below  the  umbilicus,  sometimes  as  low  as  the  pubic  sym- 
physis. The  pyloric  antrum  or  lesser  tuberosity  is  commonly 
to  the  right  of  the  median  line,  and  sometimes  is  larger  than 
it  should  be.  The  stomach  is  not  simply  enlarged,  for  there 
may  be  no  increase  in  capacitx' ;  but  the  whole  organ  descends 
in  the  abdomen,  and  this  total  displacement  downward  con- 
stitutes the  gastroptosis. 

Etiology. — The  abdominal  viscera  are  held  in  position  by 
ligaments  and  attachments  and  by  the  elasticity  of  the  abdom- 
inal wall.  The  stomach  is  supported,  also,  by  the  colon  and 
other  organs  in  the  abdominal  cavity  beneath  it,  and  ma}'  be 
displaced  by  compression,  by  traction,  and  by  its  own  unsup- 
ported weight  when  full. 

The  greater  tuberosity  of  the  stomach  lies  in  close  contact 
with  the  diaphragm,  and  may  be  displaced  downward  by  cer- 
tain diseases  of  the  thorax,  such  as  left  pleuritic  effusions, 
emphysema,  or  pericardial  effusion.     The  downward  displace- 


THE   DISPLACEMENTS   OF   THE   STOMACH.  565 

ment  of  the  diaphragm,  particularly  if  the  abdominal  wall  is 
lax  or  if  abdominal  tension  is  reduced  by  emaciation  and  by 
emptiness  of  the  intestines,  disturbs  the  equilibrium  of  the 
abdomen,  and  may  inaugurate  a  series  of  displacements  which 
will  eventually  lead  to  the  permanent  descent  of  the  stomach. 
But  often  the  displacements  are  temporary,  and  the  abdominal 
equilibrium  is  restored  after  the  diaphragm  returns  to  its  nor- 
mal position. 

Every  severe  acute  disease  leaves  the  digestive  tube  and 
the  entire  system  enfeebled.  Typhoid  fever,  severe  influenza, 
pneumonia,  and  acute  tuberculosis  are  particularly  active  in 
this  respect.  Overloading  the  motor-insufficient  stomach  dur- 
ing convalescence  drags  the  organ  down  against  the  feeble 
resistance  offered  by  its  weak  ligaments.  Moreover,  the  acute 
infectious  diseases  enlarge  the  liver  and  spleen  and  weaken 
all  the  ligaments.  The  equilibrium  of  the  abdomen  is  thus 
disturbed,  and  the  displacement  of  one  organ  after  another 
may  eventually  produce  gastroptosis. 

There  is  no  doubt  that  weak  muscular  and  fibrovascular 
systems  may  be  inherited  or  are  acquired  by  disease  during 
infancy.  Many  persons  go  through  life  afflicted  with 
weak  hearts,  weak  digestion,  weak  lungs,  torpid  liver,  and 
bad  portal  and  lymph  circulations.  This  inherited  or  early 
acquired  weakness  may  affect  particularly  the  peritoneum, 
and  may  constitute  a  particular  fibroid  dyscrasia ;  it  is  com- 
monly associated  with  gastro-intestinal  myasthenia  and  a 
consequently  variable  intra-abdominal  tension.  Be  the  patho- 
genesis what  it  may,  there  is  no  question  that  gastroptosis  is 
frequent  in  those  cursed  by  such  an  inheritance  or  by  this 
legacy  of  abdominal  disease  in  early  life. 

Gastric  retention  is  also  a  cause  of  gastroptosis.  The 
weight  of  the  full  stomach  pulls  the  organ  down,  and  its 
descent  meets  with  less  resistance  from  the  empty  intestines 
and  from  the  greater  space  in  the  abdominal  cavity  resulting 
from  the  accompanying  emaciation  and  utilization  of  the 
deposited  tissue  fat.  It  is  common  enough  to  find  gastrop- 
tosis associated  with  obstructive  and  myasthenic  retention, 
and  in  some  of  these  cases  the  total  descent  of  the  stomach 
is  a  result. 

A  very  flabby  abdominal  wall  associated  with  low  intra- 
abdominal pressure  is  another  cause  of  gastroptosis.  Preg- 
nancy, a  short  lying-in  period,  sudden  and  extreme  emacia- 
tion, the  removal  or  absorption  of  ascitic  fluid,  and  the  removal 
of  large  abdominal  tumors  are  the  chief  causes  of  the  flabby, 
collapsing  abdomen.     The  organs  and  viscera,  unsupported 


566  DISEASES  OF  THE  STOMAL//. 

in  the  erect  position,  drag  on  their  ligaments  and  attachments, 
and  descend  eventually  into  the  lower  abdomen. 

Tight  lacing  may  produce  upward,  lateral,  or  down- 
ward displacement  of  the  stomach,  according  to  the  location 
of  the  line  of  greatest  constriction  and  to  the  shape  of  waist 
produced  by  the  corset.  The  vertically  displaced  corset- 
stomach  may  undergo  prolapse.  But  when  tight  lacing,  aided 
often  by  other  causes  of  gastroptosis,  produces  total  descent 
of  the  stomach,  the  line  of  greatest  constriction  runs  across 
the  conve.x  surface  of  the  liver,  between  the  sixth  and  eighth 
ribs,  and  across  the  abdomen  near  the  ensiform  process. 
The  liver,  the  right  kidney,  the  pylorus,  the  colon,  and  the 
spleen  are  simultaneously  displaced  downward,  and  the  whole 
stomach  is  pulled  and  pressed  out  of  the  position  which  it 
normally  occupies.  The  waists  of  gastroptosis,  of  lateral 
displacement,  and  of  upward  displacement  may  be  distin- 
guished, in  their  typical  forms,  at  a  casual  glance. 

Displacements  of  the  various  abdominal  organs  usually 
occur  in  association,  and  displacement  of  one  organ  may  be 
the  cause  of  displacement  of  another.  But  it  is  certainly  an 
error  to  make  gastroptosis,  as  is  sometimes  done,  a  mere 
episode  in  the  evolution  of  enteroptosis.  Glenard  maintains 
that  the  consequences  of  prolapse  of  the  hepatic  flexure  of 
the  colon  are  descent  of  the  transverse  colon,  of  the  pylorus 
or  the  stomach,  of  the  liver,  and  of  the  right  kidney.  That 
such  is  always  the  order  of  development  can  not  be  success- 
fully defended.  The  vicious  circle  may  begin  with  any  of  the 
organs,  and  the  displacements  may  develop  partly  in  conse- 
quence of  common  causes,  partly  as  the  result  of  changing 
relations  of  the  organs  and  viscera,  producing  new  directions 
of  least  resistance.  The  tendency  is  all  downward,  on 
account  of  the  constriction  above  and  of  the  insufficient  sup- 
port below  when  in  the  erect  position.  In  two-thirds  of  the 
cases  of  gastroptosis  the  hepatic  flexure  of  the  colon  is  not 
prolapsed. 

Clinical  Description, — Gastroptosis  is  exceedingly  variable 
in  its  expression.  This  variability  is  in  keeping  with  the 
multiplicity  of  its  causation,  the  constitutions  of  its  victims, 
its  numerous  associated  displacements,  and  the  divers  dis- 
eases of  the  displaced  organs.  But  the  course  of  the  di.sease 
presents  one  pronounced  characteristic — there  is  no  tendency 
to  get  well,  nor  is  permanent  relief  obtained  without  proper 
mechanical  treatment. 

In  the  beginning,  for  a  longer  or  shorter  period,  digestive 
compensation  may  be  maintained,  and  the  symptoms  be  but 


THE   DISPLACEMENTS   OE   THE   STOMACH.  567 

little  influenced  by  the  quality  or  quantity  of  the  food.  Later, 
during  the  period  of  gastric  digestion,  the  patients  often  com- 
plain of  a  sensation  of  heaviness  or  fullness,  which  disappears 
in  the  recumbent  position  but  reappears  on  standing.  There 
is  uneasiness,  discomfort,  and  dragging  sensations  in  the 
epigastrium  and  back;  the  patient  grows  weak,  irritable,  and 
pessimistic,  and  becomes  an  invalid  without  knowing  any 
reason  for  it.  The  cause  is  discoverable  only  by  physical 
examination. 

The  motor  function  of  the  stomach  eventually  becomes 
insufficient.  There  is  gastric  stagnation,  often  heartburn, 
flatulency,  and  severe  pain.  Stagnation  in  the  colon  is  com- 
mon, and  the  constipation  may  alternate  with  diarrhea  or  the 
stools  may  consist  of  hard  lumps  coated  with  mucus  and 
mixed  with  fluid  and  gas.  Certain  foods  increase  the  symp- 
toms, which  are  now  constitutional  and  local.  Vinegar,  acid 
drinks,  wine,  and  milk  particularly  increase  the  digestive 
symptoms,  the  nervousness,  depression,  headache,  and  the 
insomnia  of  the  second  half  of  the  night.  Neurasthenic  pains 
and  tender  points  appear.  The  back  aches  and  the  lower 
extremities  are  weak.  The  patient  restricts  the  diet,  and 
loses  weight  and  strength.  These  symptoms  may  continue, 
with  exacerbations  and  remissions,  for  a  number  of  years. 
Excessive  uric  acid  formation  is  sometimes  a  symptom  of  the 
established  disease,  but  more  frequently  the  uric  acid  is 
deposited  in  the  urine  after  standing  without  an  qxcessive 
formation,  the  precipitation  being  due  simply  to  diminished 
solvent  power  of  the  urine  or  to  excessive  conversion  of  the 
neutral  phosphate  of  soda  into  the  acid  phosphate. 

The  stagnation  eventually  may  be  replaced  by  retention. 
The  emaciation  then  increases,  and  the  insomnia  becomes 
complete.  The  intestines  are  more  and  more  disordered,  and 
enteritis  membranacea,  with  alternating  stenosis  and  stagna- 
tion, is  quite  common.  The  symptoms  become  more  continu- 
ous in  character  and  more  independent  of  the  digestive  period 
and  of  the  quantity  and,  to  some  extent,  of  the  quality  of  the 
food.  They  are  but  slightly  relieved  by  the  recumbent  posi- 
tion and  by  abdominal  support.  The  dragging  sensations, 
most  pronounced  during  the  developmental  period,  usually 
disappear  in  the  course  of  the  disease.  Vomiting  is  very  infre- 
quent and  exceedingly  difficult,  the  flatulency  can  not  be  gotten 
rid  of  by  belching,  and  constipation  is  usually  obstinate.  The 
propulsion  of  the  contents  of  the  digestive  tube  is  made  more 
difficult  by  the  low  abdominal  tension,  by  the  flabby  abdomi- 
nal walls,  and   by  the  stenosed  fixed  points  of  the  digestive 


568  DISEASES    OF   THE   STOMACH. 

tube,  when  they  exist.  The  patient  is  nervous,  weak,  irrita- 
ble, anemic,  uriceniic,  and  often  neurasthenic,  and  suffers 
from  catarrh  of  more  or  less  all  the  mucous  membranes.  For- 
tunately, the  disease  seldom  arrives  at  this  advanced  stage, 
and  is  often  milder  in  its  expression  and  amenable  to  proper 
treatment. 

Symptomatology. — The  digestive  symptoms  are  variable, 
but  present  certain  characteristics  which  should  excite  sus- 
picion and  lead  to  a  careful  physical  examination  of  the  stom- 
ach. The  heaviness  in  the  stomach  after  eating  or  drinking, 
the  heartburn,  flatulency,  belching,  and  regurgitation,  are 
symptoms  of  myasthenia.  But  rest  in  bed  or  rest  during 
the  period  of  gastric  digestion  causes  them  to  disappear 
rapidly.  The  peculiar  digestive  discomfort  and  heaviness 
are  relieved,  even  while  the  patient  is  in  the  erect  position,  by 
supporting  the  stomach,  and  they  return  as  soon  as  the  organ 
is  released. 

There  are  local  pains  independent  of  digestion  and  of  the 
quality  of  the  food.  These  pains  are  produced  by  stretching 
of  the  nerve  filaments  in  the  supporting  ligaments,  and,  possi- 
bly, by  a  local  peritonitis  produced  by  a  tear  or  detachment 
of  the  peritoneum.  The  latter  is  not  a  plausible  explanation 
except  when  the  displacement  has  been  rapidly  produced  :  as, 
for  example,  by  traumatism  or  strain.  The  pain  is  sometimes 
severe,  and  is  associated  often  with  a  peculiar  local  uneasiness 
or  discomfort.  The  severe  pain  has  two  common  locations — 
sometimes  beneath  the  ensiform  process,  and  sometimes  near 
the  left  costal  border  just  above  the  level  of  the  umbilicus. 
The  pain  is  excited  by  effort,  by  dancing,  by  jolting,  often 
simply  by  a  short  walk.  The  severe  pain  may  be  accom- 
panied by  spasm  of  the  diaphragm,  by  rapid  pulse,  by 
dilatation  of  the  pupils,  and  by  sudden  changes  in  the  color 
of  the  face.  Some  of  these  symptoms  are  doubtless  due 
to  the  intense  irritation  of  the  abdominal  sympathetic 
nerve. 

Extreme  and  unaccountable  weakness  is  a  common  symp- 
tom of  gastroptosis,  particularly  when  the  disease  is  associated 
with  a  flabby  abdomen  and  when  it  develops  as  a  sequel  of  the 
puerperium.  The  mother's  attention  is  fixed  on  the  weak- 
ness and  anemia,  both  of  which  increase  so  that  the  diges- 
tive disturbance  is  overlooked ;  while  the  physician  is  likely 
to  suspect  or  incriminate  the  uterus,  which,  indeed,  is  often 
retroverted  or  prolapsed.  But  the  chief  trouble  is  the  gas- 
troptosis   (sometimes    splanchnoptosis)    and    the    diminished 


THE   DISPLACEMENTS    OF   THE   STOMACH.  569 

abdominal  tension.  No  relief  is  obtained  until  these  are 
properly  treated. 

Neurasthenia  is  one  of  the  occasional  results  of  gastrop- 
tosis.  It  presents  no  distinctive  characteristics,  except  its 
association  with  the  physical  signs  of  the  displacement,  and 
its  cure  by  the  proper  treatment  of  the  gastroptosis. 

Periodical  headache  is  sometimes  a  symptom  of  gastrop- 
tosis, and  seems  to  be  due  to  the  irritation  of  retained  food 
and  of  excessive  secretion.  During  the  premonitory  period 
the  patient  is  nervous  and  restless,  is  constipated,  and  has 
often  a  little  brow-ache  in  the  morning.  During  the  par- 
oxysm the  headache  is  severe,  and  is  accompanied  by  precor- 
dial pain  and  great  irritability  of  the  sympathetic.  The  appe- 
tite is  now  completely  lost.  The  attack  ends  with  vomiting 
of  food,  some  of  which  has  been  retained  for  two  or  three 
days;  the  vomit  may  be  excessively  rich  in  hydrochloric 
acid.  This  headache  of  gastroptosis  is  often  confounded 
with  migraine  and  adenohypersthenia  gastrica.  Its  distinc- 
tive characteristic  is  the  existence  of  the  causative  gastrop- 
tosis. 

The  objective  signs  are  distinctive.  On  inspection,  the 
form  of  the  abdomen  is  often  suggestive,  the  lower  part  being 
full  or  flabby  and  the  epigastrium  depressed.  The  contour 
of  the  stomach  during  the  period  of  digestion  can  often  be 
outlined  on  the  abdominal  wall  by  the  practised  eye.  The 
lesser  curvature  runs  across  the  abdomen  lower  than  aormal  ; 
the  greater  curvature  is  often  below  the  navel,  and  may 
descend  even  as  low  as  the  symphysis.  The  greater  curva- 
ture is  not  only  lowered,  but  it  extends  much  further  to 
the  left  and  further  to  the  right  of  the  median  line  than  it 
should  go. 

If  the  stomach  is  empty,  and,  on  percussion,  the  larger 
part  of  the  semilunar  space  of  Traube  is  dull,  and  if  this  dul- 
ness  does  not  disappear  when  the  stomach  is  inflated,  the 
superior  limit  of  the  stomach  is  lowered.  Care  should 
naturally  be  taken  to  exclude  pleurisy,  pericarditis  with 
effusion,  consolidation  of  the  lower  lobe  of  the  left  lung,  and 
other  thoracic  conditions  which  would  diminish  the  resonance 
of  this  same  area. 

On  inflation  the  curvatures  can  usually  be  located  with 
accuracy.  The  descent  of  the  lesser  curvature  and  of  the 
fundus  are  characteristic  signs.  The  greater  curvature  can 
naturally  be  found  below  the  umbilicus  when  the  stomach  is 
simply  enlarged  by  gluttony,  by  pyloric  or  duodenal  obstruc- 
tion, in  cases  of  advanced  myasthenia,  and  when  the  stomach 


570  DISEASES   OE   THE   STOMACH. 

is  vertically  displaced.  The  pylorus  is  usually  lower  than 
its  normal  position,  and  can  be  located  by  inspection  after  in- 
flation and  by  palpation  ;  it  can  be  identified,  also,  by  the 
periodical  bubbling  of  the  contents  of  the  stomach  through  it. 
The  epigastrium  above  the  lesser  curvature  is  dull  on  percus- 
sion, and  the  pancreas  and  left  lobe  of  the  liver  can  often  be 
felt  lying  over  the  vertebral  column  and  over  the  pulsating 
aorta.  There  often  exists  a  painful,  sharp!}'  limited,  tender 
and  epigastric  point  like  that  of  ulcer;  but  a  distinguishing 
sign  is  the  absence  of  the  stomach  beneath  the  tender  point 
of  gastroptosis.  In  extreme  gastroptosis  with  low  abdominal 
tension,  the  epigastrium  may  possibly  be  occupied  by  coils  of 
the  intestines.  Electric  illumination  of  the  stomach  often 
produces  a  characteristic  picture,  but  is  not  required  for  mak- 
ing the  diagnosis.  The  other  physical  signs  locate  the 
stomach  with  greater  ease  and  certainty. 

The  prolapsed  stomach  is  not  so  closely  associated  with 
the  movements  of  the  diaphragm  as  when  in  its  normal 
position.  It  often  moves  but  little  on  either  inspiration  or  ex- 
piration, is  easily  fi.Ked  during  expiration,  and  can  be  grasped 
and  readily  moved  about  in  the  often  flabby  abdomen. 

The  left  lobe  of  the  liver  and  the  sympathetic  ganglia  will 
often  be  found  sensitive  to  pressure.  This  is  in  part  due  to  the 
ease  with  which  firm  pressure  can  be  brought  to  bear 
almost  directly.  When  associated  with  the  severe  pain  of 
effort  beneath  the  ensiform  process,  and  with  neurasthenic 
tender  points,  the  inexperienced  may  be  led  to  suspect  an 
ulcer. 

The  functional  signs  are  in  no  manner  characteristic  of 
gastroptosis,  but  are  of  value  in  the  revelation  of  complica- 
tions and  in  the  regulation  of  the  diet  and  treatment.  In 
the  same  respect  the  bacteriological  and  anatomical  signs  may 
be  useful. 

Differential  Diagnosis. — The  prolapsed  stomach  nia}' become 
diseased  in  the  same  manner  as  when  in  its  normal  position. 
Associated  with  it  may  be  found  any  of  the  anatomical 
diseases  of  the  stomach  and  many  of  the  dynamic  affections. 
The  diagnosis  of  the  gastroptosis  rests  exclusively  on  its 
physical  signs,  and  its  causal  relation  to  the  associated  disease 
often  can  not  be  deternn'ned.  The  clinical  history  may  con- 
tain some  distinctive  features  in  favor  of  the  priority  of  the 
displacement  of  the  stomach,  which,  as  may  be  expected,  is 
very  favorable  to  the  development  of  other  gastric  troubles. 
The   solution  of  the  problem,  however,  is  of  little  practical 


THE   DISPLACEMENTS   OF   THE   STOMACH.  57 1 

moment,  for  the  treatment  must  be  that  of  the  two  diseases 
combined. 

But  gastroptosis  is  liable  to  be  confounded  with  myasthenia, 
and  with  pyloric  and  duodenal  obstruction.  There  are  sev- 
eral signs  which,  although  not  conclusive,  are  in  favor  of 
gastroptosis.  The  flabby  and  prominent  lower  abdomen,  the 
constricted  waist,  and  the  development  of  the  gastric  trouble 
as  a  sequel  of  pregnancy  should  create  suspicion  of  the  dis- 
placement. The  great  relief  afforded,  particularly  during 
digestion,  by  the  proper  support  and  gentle  compression  of 
the  abdomen  below  the  umbilicus  is  another  valuable  differ- 
ential sign.  The  existence  of  a  movable  right  kidney,  of  a 
displaced  and  deformed  liver,  of  a  displaced  and  chronically 
inflamed  colon,  constipation,  scybala  coated  with  mucus, 
membrane-like  shreds,  alternating  enterostenosis  and  dilata- 
tion, are  most  common  in  association  with  gastroptosis.  But 
none  of  these  signs  is  conclusive,  and  the  diagnosis  can  only 
be  made  sure  by  the  accurate  delimitation  of  the  stomach, 
demonstrating  the  total  descent  of  the  organ,  which  is  made 
clear  by  the  position  of  its  superior  border. 

In  long-standing  cases  of  myasthenia,  particularly  in  the 
severe  stagnation  and  retention  stages,  the  stomach,  with  its 
often  weakened  attachments,  may  become  prolapsed.  In 
obstructive  stagnation  and  retention  the  same  displacement 
may  result.  In  complicated  gastroptosis  the  contents  of  the 
stomach  may  stagnate  or  be  retained.  Consequently,  the 
mere  presence  of  gastroptosis  does  not  prove  that  there  may 
not  be  a  primary  myasthenia  or  obstruction.  If  there  is  no 
stagnation,  myasthenia  is  thereby  excluded,  as  is  also  a  possi- 
ble compensated  obstruction,  for  the  latter  does  not  produce 
gastroptosis.  If  there  is  stagnation  or  retention,  and  if  the 
physical  signs  of  gastroptosis  are  present,  the  primary  trouble 
may  be  the  displacement,  the  myasthenia,  or  the  obstruction. 

Gastroptosis  may  produce  a  kink  obstruction  of  the  first 
part  of  the  duodenum,  and  may  with  great  difficulty  be  dis- 
tinguished from  other  forms  of  obstructive  stagnation  and 
retention.  In  gastroptosis  the  reposition  and  support  of  the 
stomach  remove  the  obstruction  and  cure  the  stagnation  or 
retention,  provided  the  muscular  coat  is  not  asthenic  ;  this  is 
an  absolute  differential  sign.  Rest  in  bed  improves  digestion 
in  gastroptosis,  immediately  and  greatly ;  it  is  much  less 
beneficial  in  organic  obstruction.  The  absence  of  any  palpa- 
ble cause  of  obstruction  is  in  favor  of  gastroptosis.  When 
the  prolapsed  stomach  is  myasthenic,  the  differential  signs 
given  in  the  chapter  on  Pyloric  Obstruction  become  applicable. 


572  DISEASES   OF   THE  STOMACH. 

Is  tlie  niyastlienia  or  the  gastroptosis  primary  ?  The  his- 
tory and  the  existence  of  associated  displacements  may  throw 
some  light  on  the  case,  but  without  a  knowledge  of  the 
evolution,  an  etiological  diagnosis  is  not  possible. 

Prognosis. — Gastroptosis  is  seldom  completely  cured — the 
displacement  may  be  corrected,  but  it  readily  returns.  A 
cure  is  possible  in  the  early  stages,  particularly  when  a  flabby 
abdominal  wall  is  the  occasion  of  the  prolapse  of  the  organ. 
However,  by  proper  treatment  great  and  often  complete 
relief  can  be  given  in  even  its  most  advanced  stages. 

Treatment. — The  treatment  of  gastroptosis  is  simple  and 
methodical,  and  will  usually  prove  efficient.  The  indications 
to  be  met  may  be  thus  formulated:  (i)  To  replace  and  sup- 
port the  stomach;  (2)  to  regulate  abdominal  tension  ;  (3)  to 
nourish  the  patient  properly ;  (4)  to  prevent  stagnation;  (5) 
to  treat  the  complication  ;  (6)  to  relieve  the  symptoms. 

Before  replacing  the  stomach  it  is  first  necessary  to  make 
room  for  it.  Whether  it  be  forced  out  of  position  in  the  man- 
ner already  described,  or  let  fall  by  its  relaxed  supports,  or 
dragged  out  of  position  by  the  attached  colon,  the  room 
which  it  normally  occupies  is  filled  by  other  organs  or  by 
the  collapse  of  the  pliable  wall  of  the  upper  abdominal  cavity. 
Consequently,  the  spleen  and  liver,  if  enlarged,  should  be 
reduced  in  size  by  proper  treatment;  a  compressing  tumor  or 
thoracic  effusion  should  be  removed.  The  constriction,  col- 
lapse, and  arrested  development  of  the  waist  should  be  cor- 
rected by  properly-fitting  clothing,  by  the  support  of  all  skirts 
from  the  shoulders,  and  by  methodical  breathing  exercises, 
combined  with  arm  and  trunk  movements.  The  development 
and  expansion  of  the  upper  abdominal  wall  can  also  be  aided 
by  massage. 

The  restoration  of  the  normal  space  for  the  stomach,  it 
need  not  be  said,  is  much  more  difficult  in  some  cases  than 
in  others.  A  stomach  which  has  recently  been  dragged 
down  into  the  flabby  lower  abdomen  by  the  weight  of  its 
stagnant  or  retained  contents  or  by  the  attached  prolapsed 
colon  is  more  readily  replaced  than  one  which  has  been 
forced  out  of  position  or  one  whose  normal  position  has  been 
filled  by  the  hardened,  collapsed,  and  badly  developed  costo- 
cartilaginous  framework.  The  prolapsed  stomach,  like  the 
contents  of  a  hernia,  may  forfeit  its  right  of  domicile.  When 
the  gastroptosis  occurs  in  young  girls,  and  the  expansion  and 
development  of  the  waist  have  been  arrested  by  tight  cloth- 
ing, it  is  exceedingly  difficult  and  often  impossible,  later  in 
life,  to  recreate  for  the  stomach  its  lost  normal  space.     Natu- 


THE   DISPLACEMENTS   OF   THE   STOMACH.  573 

rally,  the  stomach  can  not  often  be  returned  to  its  normal 
position  like  a  reducible  hernia.  Gradual  replacement  of  the 
stomach,  however,  is  essential  to  a  perfect  cure ;  otherwise 
the  treatment  can  only  be  palliative  and  arrest  the  further 
evolution  of  the  trouble. 

In  order  to  support  the  replaced  stomach  the  elasticity  of 
its  ligaments  must  be  restored,  the  abdominal  wall  strength- 
ened, and  the  intestines — which  form  a  sort  of  cushion  on 
which  the  stomach  rests  when  the  body  is  erect — be  held  well 
up  in  the  abdomen.  Massage,  electricity,  improved  nutrition, 
and  neuromuscular  tone  are  slowly-working  but  valuable  aids 
to  this  end.  But  to  give  immediate  relief,  the  lower  abdomen 
must  be  supported  by  an  elastic  belt. 

The  pelvic  or  hypogastric  belts  of  Glenard,  Teufel,  Rarden- 
heur,  and  Landau,  when  made  so  as  to  fit,  and  slightly  modi- 
fied so  as  to  suit  each  individual  case,  do  well  the  work  which 
is  required  of  them — an  elastic  and  gentle  compression  and 
proper  support  of  the  contents  of  the  abdominal  cavity  below 
the  navel.  We  have  found  it  best  to  have  the  belt  made  to 
order,  and  to  adapt  it,  by  modification,  to  the  requirements  of 
each  case.  The  belt  should  be  applied  next  to  the  skin  in  the 
morning  while  the  stomach  is  empty,  with  the  patient  in  bed  ; 
it  should  be  tightened  from  below  upward.  In  severe  cases 
the  bandage  should  be  applied  while  the  patient  is  in  the  knee- 
chest  posture.  When  the  abdomen  is  very  flabby  it  may  be 
necessary  to  wear  the  belt  day  and  night;  but  usually,  unless 
abdominal  tension  is  very  low,  it  may  be  removed  before 
retiring. 

In  nearly  every  case  of  gastroptosis  which  has  not  been 
produced  by  downward  pressure  and  by  the  excessive  weight 
of  the  retained  contents,  intra-abdominal  tension  is  too  low. 
This  is  one  of  the  causes  of  the  inefficient  peristalsis  and  of 
the  stasis  of  the  contents  of  the  digestive  tube.  But  persist- 
ent low  tension  means  venous  and  particularly  lymph  stasis 
or  congestion.  This  abdominal  stagnation  is  pernicious  in  its 
influence  on  the  nutrition  of  the  abdominal  and  pelvic  organs, 
and  on  digestion,  absorption,  and  assimilation.  Consequently, 
the  coexistence  of  gastroptosis  and  low  abdominal  tension 
strongly  condemns  purgation  or  reducing  treatment  of  any 
kind.  Rest,  massage,  electricity,  an  elastic  abdominal  belt,  a 
proper  diet,  supplemented,  if  need  be,  by  gentle  laxatives,  are 
more  rational  and  beneficial. 

Rest  in  bed  is  a  most  valuable  remedy.  During  the  devel- 
opment of  gastroptosis — and  the  displacement  may  often  be 
detected  in  its  beginning  by  a  careful  physical  examination — 


574  DISEASES   OF   THE   STOMACH. 

the  patient  should  be  given  a  methodical  rest-cure.  The 
evolution  of  the  trouble  would  be  at  once  cut  short;  the 
drat^s^ing  pains,  the  tender  points,  nervousness,  neurasthenia, 
and  anemia  grow  less.  Rest  is  essential  in  the  cure  of  the 
secondary  anemia  and  neurasthenia  of  gastroptosis.  The 
mild  cases  of  total  descent  of  the  stomach — and  these  cases 
are  numerous — may  be  treated  with  only  the  amount  of  rest 
requisite  to  good  digestive  hygiene — half  an  hour's  rest 
before  and  after  each  meal.  Often  it  will  be  advantageous  to 
enforce  rest  on  the  lounge  during  the  greater  part  of  gastric 
digestion. 

The  diet  in  gastroptosis  is  variable  on  account  of  the 
large  number  of  complications,  and  is  determined  by  the 
functional  power  of  the  stomach,  by  the  state  of  the  intes- 
tines, and  by  the  needs  of  nutrition.  As  a  rule,  in  gastrop- 
tosis the  patient  is  pale,  somewhat  emaciated,  and  badly 
nourished.  Abdominal  tension  is  decreased  and  the  organs 
are  more  easily  displaced  as  the  mesenteric,  omental,  and 
kidney  fat  disappear.  At  lea.st  a  diet  of  support  is  an  invar- 
iable rule,  and  it  is  best  to  improve  nutrition  as  rapidly  as 
possible  by  proper  and  nourishing  food,  such  as  each  par- 
ticular patient  can  utilize.  A  reducing  and  insufficient  diet 
can  only  do  harm  in  simple  gastroptosis,  but  it  may  be  made 
necessary  by  a  severe  complication,  such  as  chronic  colitis. 

Gastroptosis,  when  associated  with  healthy  intestines  and 
good  motor  compensation,  requires  only  a  nourishing  diet, 
measures  to  open  the  way  gradual  1\'  for  the  return  of  the 
stomach  to  its  normal  position,  and  good  digestive  hygiene. 
The  diet  should  consist  of  plain  and  nutritious  food,  tender 
meats,  fish,  game,  eggs,  thoroughly  cooked  cereals,  the 
more  digestible  vegetables,  and  a  moderate  quantity  of  sweets 
and  fruits.  The  fat  should  not  be  diminished.  In  this  stage 
there  is  no  objection  to  milk,  if  it  is  digested  by  the  partic- 
ular patient.  Pastry,  rich  sauces,  coarse  vegetables,  indiges- 
tible articles,  and  most  alcoholic  drinks  should  be  excluded. - 

Gastroptosis  with  myasthenia  requires  a  diet  suited  to  the 
stages  of  this  complication  ;  this  diet  has  been  given  in  the 
chapter  on  Myasthenia  Gastrica.  The  drugs  which  have 
a  special  tonic  action  on  the  involuntary  muscles  should 
be  prescribed — strychnin,  hydrastinin,  cinchona,  and  some- 
times ergot  and  ipecac  ;  all  in  small  doses.  Electricity  and 
hydrotherapy  are  even  more  valuable.  Faradism,  both  gen- 
eral and  gastric,  should  be  used,  and  the  needle  bath  with 
hot,  followed  by  cold,  water  over  the  abdomen  and  lower  ex- 
tremities.     All    hygienic   measures   which    give  tone  to  the 


THE  DISPLACEMENTS   OF   THE   STOMACH.  575 

neuromuscular  system  should  be  employed.  Briefly,  the 
treatment  is  that  of  the  myasthenia  (already  given)  plus  the 
treatment  of  the  displacement.  Rest  in  bed  for  a  variable 
period  is  sometimes  necessary. 

Gastroptosis  associated  with  chronic  colitis  requires  a  very 
carefully  selected  diet,  abdominal  support,  digestive  hygiene, 
often  rest  in  bed,  the  cold  or  hot  compress,  the  prevention  of 
stasis,  and  the  use  of  alkalies.  The  diet,  for  a  short  period, 
should  consist  almost  exclusively  of  tender  or  chopped 
meats  and  poultry  (white  meat),  either  roasted  or  broiled,  a 
little  dry  toast,  crust  of  roll,  the  expressed  juice  of  meats, 
once  a  day  a  i&\w  spoonfuls  of  a  clear  vegetable  soup  thick- 
ened with  thoroughly  cooked  barley  gruel,  rice,  or  de- 
corticated whole  meal.  No  wine,  milk,  acids,  fruits,  or 
vegetables  should  be  allowed.  Half  an  ounce  of  fresh, 
unsalted  butter  should  be  eaten  daily.  During  the  employ- 
ment of  this  restricted  diet  the  patient  should  spend  nearly 
the  whole  time  in  bed  or  on  the  lounge,  in  order  to  reduce 
the  needs  of  nutrition  to  a  minimum.  After  a  few  weeks 
fresh  lean  meats,  preparations  of  wheat  or  rice,  the  white 
of  eggs  with  a  little  of  the  yolk,  the  juice  of  a  few  grapes, 
a  baked  apple,  stewed  prunes,  and  the  juice  of  an  orange 
may  be  added.  A  {&\\  months  later  a  mixed  diet  of  plain 
foods  should  be  prescribed,  and  rigorously  adhered  to  until 
the  patient  is  well.  A  glass  of  Vichy  (Celestins,  Grande- 
Grille)  should  be  given  daily,  an  hour  before  breakfast,  par- 
ticularly when  the  stools  are  very  acid,  contain  much  fat,  or 
the  urine  deposits  uric  acid  on  standing  ;  enough  sulphate  of 
soda  should  be  added  to  the  Vichy  to  produce  a  full  and  soft 
stool.  The  abdominal  belt  decreases  the  constipation,  and 
the  compress  relieves  the  excessive  irritability.  If  the  motor 
power  of  the  stomach  is  normal,  a  dose  of  Carlsbad  salts  or 
other  saline  (only  one  movement)  may  be  given  daily,  or  three 
times  a  week  for  one  month.  Cascara  is  the  most  harmless 
and  valuable  laxative.  Hydrastinin,  strychnin,  cinchona, 
ipecac,  and  possibly  belladonna,  are  often  useful  in  small 
doses.  But  only  the  gentlest  measures  that  are  effective  in 
the  particular  case  should  be  employed  to  prevent  the  stasis 
of  the  contents  of  the  colon.  The  localized  spasmodic 
strictures  of  the  colon  are  sometimes  very  much  benefited 
by  injections  of  warm  pure  sweet  oil,  to  which  two  teaspoon- 
fuls  of  oil  of  hyoscyamus  (G.  P.)  may  be  added. 

Gastroptosis  with  neurasthenia  requires  rest  in  bed.  The 
digestive  tube  must  be  kept  perfectly  free  from  irritation  by 
food,  by  fermentation  or  putrefaction  products,  and  by  drugs. 


576  DISEASES   OF   THE   STOMACH. 

A  milk-  and  rest-cure  often  yields  excellent  results  when  com- 
bined with  massage,  electricity,  hydrotherapy,  and  proper 
moral  treatment.  If  pure  milk  disagrees,  it  may  be  tried 
combined  with  alkalies,  or  a  fermented  preparation  of  milk 
may  be  substituted.  Cod-liver  oil  may  often  be  given  at  the 
same  time  with  benefit.  White  meat  of  poultry  and  game, 
fresh  lean  fish,  preparations  of  wheat  and  rice  and  other 
cereals,  a  little  dry  toast  and  butter,  and  sometimes  eggs,  may 
be  added  to  the  list  after  a  few  days.  After  all  the  neuras- 
thenic signs  are  gone,  red  meats,  green  vegetables,  and  unirri- 
tating  fruit  may  be  permitted;  but  their  digestion,  utilization, 
and  subjective  effects  should  be  watched.  Most  drugs  are 
badly  borne,  and  should  be  employed  sparingly,  and  chiefly 
to  meet  functional  indications.  As  in  other  forms  of  gas- 
troptosis,  the  stomach  should  be  supported  and  abdominal 
tension  regulated  by  a  suitable  hypogastric  belt. 

It  will  thus  be  readily  seen  that  the  treatment  of  gastroptosis 
does  not  consist  in  the  routine  use  of  certain  remedies.  Each 
case  requires  special  remedies,  particularly  when  the  disease 
is  complicated.  Each  individual  has  his  own  peculiarities  and 
constitution,  demanding  particular  modifications  of  the  medi- 
cation employed.  But  all  cases  are  alike  in  requiring  pro- 
longed and  methodical  treatment  in  order  to  establish  and 
maintain  digestive  compensation  or  to  effect  a  cure.  Pain, 
insomnia,  headache,  nervousness,  and  uricemia  often  require 
symptomatic  remedies. 


CHAPTER  V. 

OBSTRUCTION  OF  THE  ORIFICES. 

The  organic  obstruction  of  the  cardia  and  of  the  pylorus  are 
diseases — or,  more  properly,  deformities — which  may  require 
operation  for  their  relief.  The  obstruction  is  nearly  always 
due  to  ulcer,  to  cancer,  or  to  toxic  gastritis,  and  is  then  only  an 
episode  or  a  sequel  of  these  diseases.  But  there  are  also  other 
rare  causes,  and  when  the  obstruction  occurs  a  condition 
results  which  has  a  characteristic  symptomatology,  demands 
special  treatment,  and  presents  many  difficulties  in  differential 
diagnosis.  The  practical  value  of  a  close  study  of  this  sub- 
ject is  obvious,  for  the  surgeon  stands  hard  by,  ready  to  put 
the  physician's  opinion  to  the  test. 


OBSTRUCTION  OF  THE    ORIFICES.  577 

I.  Obstruction  of  the  Cardia. — Obstruction  of  the  cardia 
is  a  very  serious  condition,  usually  preventing  the  ingestion 
and  absorption  of  enough  food  to  maintain  the  nutrition  of 
the  body.  The  inanition  is  more  or  less  complete  and  rapid, 
according  to  the  degree  of  the  stenosis.  The  body  may 
sometimes  be  nourished  on  a  carefully  selected  diet  after  it  is 
no  longer  possible  to  swallow  solid  food.  But  the  obstruction 
may  become  so  great  as  to  allow  only  a  little  or  even  no 
liquid  nourishment  to  pass.  The  beginning  of  inanition, 
except  in  cancerous  obstruction,  marks  a  turning-point  in  the 
treatment  of  the  condition ;  and  then  feeding  by  bowel, 
through  an  esophageal  cannula  or  through  a  gastric  fistula, 
must  be  employed.  Surgical  interference  is  imperative  when 
starvation  begins. 

Etiology. — Obstruction  of  the  cardia  is  much  less  frequent 
than  the  same  deformity  of  the  pylorus,  but  both  are  alike  in 
the  multiplicity  of  their  manner  of  production. 

The  causative  disease  originates  in  the  wall  of  the  digestive 
tube  in  the  vicinity  of  the  orifice,  or  the  obstruction  may  be 
due  to  the  compression  of  a  mediastinal  or  retroperitoneal 
tumor,  a  cold  abscess,  enlarged  glands,  or  aneurysm.  Con- 
genital atresia  is  exceedingly  rare,  the  ectodermic  esophagus 
developing  and  forming  a  complete  and  perfect  union  with 
the  endodermic  stomach.  Congenital  obstructive  malforma- 
tion of  this  part  of  the  digestive  tube  is  scarcely  known. 

Stenosis  of  the  cardia  may  be  spasmodic,  and  is  then  com- 
monly known  as  esophagismus.  Spasmodic  stricture  is  not 
very  rare,  and  may  occur  at  any  age.  Organic  strictures  are 
often  made  tighter  by  spasm  of  the  cardia. 

Cicatricial  contraction  is  one  of  the  common  causes  of 
organic  obstruction.  Tubercular  and  syphilitic  ulcers  very 
seldom  occur  at  this  point  of  the  digestive  tube.  Ulcer  of  the 
stomach  does  not  often  involve  the  cardia.  Catarrhal  and 
corrosive  ulceration  is  more  frequent,  the  cardia  being  the 
first  point  of  arrest  in  the  gullet  of  corrosive  acids,  alkalies, 
or  salts.  Consequently,  these  chemicals  commonly  produce 
stricture  of  the  lower  part  of  the  esophagus. 

The  most  common  cause  of  cardiac  stenosis  is  cancer, 
extending  to  it  either  from  the  esophagus  or  the  stomach,  and 
composed  histologically  of  pavement  or  cylindrical  cells.  If 
it  be  remembered  that  the  number  of  deaths  due  to  cancer  of 
the  stomach  is  small,  and  that  only  a  small  number  of  gastric 
carcinomata  involve  the  cardia,  it  will  readily  appear  that 
stenosis  of  the  cardia,  including  all  its  varieties,  is  not  a  fre- 
quent deformity. 
37 


578  DISEASES  OF  THE  STOMACH. 

Clinical  Description. — The  manifestations  and  evolution  of 
obstruction  of  the  cardia  are  variable.  Some  of  the  symp- 
toms are  due  to  the  obstruction  itself  and  to  its  conse- 
quences— dysphagia,  esophageal  stagnation,  and  inanition. 
Others  are  due  to  the  causative  disease  located  in  the  wall 
of  the  tube  or  in  its  vicinity.  The  modifications  of  the 
clinical  picture  entailed  by  the  method  of  production  will 
be  discussed  under  the  etiological  diagnosis. 

The  first  symptom  of  obstruction  is  the  arrest  of  food  in 
the  lower  portion  of  the  esophagus.  The  patient  states  that 
solid  food  seems  to  stick  at  that  point,  and  that  it  requires  a 
deep  inspiration  and  repeated  efforts  at  swallowing  to  force  it 
on.  This  sensation  will  most  likely  be  noticed  first  after  a 
large  bolus  is  swallowed,  but  later  small  mouthfuls  of  solid 
food  and  the  very  rapid  gulping  of  liquids  produce  the  same 
sensations.  Solid  food  can  be  made  to  pass  readily  only  by 
swallowing  a  little  at  a  time  and  washing  it  down  with 
fluids.  The  meal  can  be  finished  comfortably  only  when 
eaten  slowly  and  in  small  mouthfuls.  The  obstruction  mani- 
fests itself  only  during  eating. 

Soon  the  signs  of  esophageal  stagnation  appear.  After 
the  meal  is  finished  there  seems  to  be,  beneath  the  lower  end 
of  the  sternum,  a  foreign  body  which  gives  a  good  deal  of 
discomfort  and  anxiety  from  the  compression  which  it  exerts. 
The  symptom  is  in  direct  relation  with  the  solidity  of  the 
food,  the  rapidity  of  eating,  and  the  heartiness  of  the  meal. 
The  food  frequently  regurgitates  into  the  mouth,  particularly 
after  coughing.  Chemical  tests  will  show  that  the  matter 
regurgitated  has  not  entered  the  stomach,  but  it  is  often 
mixed  with  a  good  deal  of  mucus  from  the  local  irritation 
which  the  stagnation  or  the  causative  disease  excites.  This 
sensation  of  a  foreign  body  beneath  the  sternum  may  be  due 
in  part  to  the  obstructing  tumor. 

Later,  stagnation  is  replaced  by  retention.  The  food  fer- 
ments, decomposes,  irritates,  and  the  contents  of  the  dilated 
pouch  are  regurgitated  again  and  again  into  the  mouth, 
mixed  with  mucus  and  saliva;  they  are  sometimes  foul,  and 
contain  no  bile,  hydrochloric  acid,  pepsin,  labferment,  nor 
products  of  gastric  digestion. 

The  stagnation  and  retention  produce  secondary  thoracic 
symptoms.  There  may  be  dyspnea,  often  discomfort  or  pain, 
increased  by  e.xercise,  and  sometimes  attacks  of  pseudo- 
angina  pectoris.  The  obstruction  may  be  increased  by  spasm 
of  the  cardia  and  by  inflammatory  swelling,  or  it  may  be 
diminished  by  ulceration.     Consequently,  organic  obstruction 


OBSTRUCTION   OF   THE    ORIFICES.  S79 

of  the  cardia  usually  presents  periods  of  diminution  and  of 
increase,  and  eventually,  and  more  or  less  rapidly,  in  keeping 
with  the  nature  of  the  cause,  may  become  complete. 

If,  on  account  of  the  obstruction,  too  little  food  is  received 
into  the  stomach,  nutrition  suffers.  The  symptoms  are  those 
of  simple  subnutrition — thirst,  hunger,  emaciation,  weakness, 
and  the  particular  functional  and  nervous  signs  due  to  a  con- 
stant deficiency  of  food  and  water.  The  stomach  and  bowels 
are  particularly  liable  to  retract.  To  the  obstructive  and 
denutritive  manifestations  will  naturally  be  added  those  ex- 
pressive of  the  causative  disease ;  for  the  obstruction  of  the 
cardia  itself  may  be  congenital,  or  an  episode,  or  a  sequel. 

Symptomatology. — One  of  the  earliest  signs  of  obstruc- 
tion of  the  cardia  is  the  arrest  of  solid  food  in  the  lower 
portion  of  the  esophagus.  The  food  sticks  at  this  point  and 
requires  repeated  efforts  to  force  it  on.  In  the  case  of  ulcer, 
this  arrest  is  preceded  by  a  period  when  the  swallowing  and 
the  movements  of  active  respiration  are  painful.  As  the  ulcer 
heals  and  the  cicatrix  forms,  the  pain  gives  place  to  obstruc- 
tion. First  solids,  and  then  liquids,  are  arrested,  and,  finally, 
only  a  small  quantity  of  liquid  food  or  none  can  be  forced 
into  the  stomach.  Cicatricial  constriction  often  stops  before 
occlusion  is  complete,  and  remains  for  a  long  time  stationary. 
The  obstructions  of  carcinoma  and  of  growing  and  com- 
pressing tumors  are  progressive.  In  cancer  the  obstruction 
may  be  diminished  by  ulceration,  and  the  consequent  im- 
provement in  swallowing  gives  rise  to  false  hopes.  The  ob- 
struction is  often  increased  by  spasm  and  swelling,  and  the 
food  passes  more  easily  when  the  irritation  and  inflammation 
subside.  The  irritation  produced  by  passing  a  sound  may 
cause  complete  occlusion  for  a  few  days.  The  period  of  com- 
pensatory hypertrophy  of  the  esophagus  is  short  when  car- 
cinoma is  present,  and  inspiratory  compression,  instead  of 
forcing  the  food  into  the  stomach,  only  brings  it  up  into  the 
mouth.  In  organic  obstruction  there  are  no  periods  when 
swallowing  is  effortless  and  normal,  as  there  are  in  esopha- 
gismus. 

The  regurgitation  is  at  first  alimentary,  and  is  limited  to 
the  period  during  the  taking  of  food  or  shortly  afterward. 
Later,  as  stagnation  and  retention  develop,  it  occurs  between 
meals,  consisting  of  repeated  mouthfuls  of  food,  of  saliva  and 
mucus,  or  of  all  mixed  together,  and  being  sometimes  fer- 
mented and  putrid,  particularly  in  carcinoma.  The  persistent 
absence  of  any  chemical  evidence  that  the  regurgitated 
matter  has  entered  the  stomach  is  characteristic  of  esophageal 


580  DISEASES  OF  THE  STOMACH. 

vomiting,  which  in  some  cases  may  be  accompanied  by 
nausea.  Blood  may  sometimes  be  brought  up  when  there  is 
ulceration  or  when  there  are  dilated  cardio-esophageal  veins. 

Pain  may  be  entirely  absent  or  it  may  be  severe,  and  where 
there  is  no  great  stagnation  or  retention  it  may  be  confined 
to  the  mealtime.  Sometimes,  however,  as  the  pocket  forms 
and  fills,  or  when  there  is  ulceration,  the  pain  is  severe, 
located  near  the  ensiform  process,  and  radiates  into  the  back 
and  concentrates  about  the  heart.  It  may  be  accompanied  by 
dyspnea  or  hiccup,  and  is  likely  to  be  increased  by  exer- 
cise and  deep  breathing.  Sometimes  the  pain  is  excited  by 
walking,  and  disappears  as  the  esophagus  empties  itself. 

The  physical  signs  are  very  valuable  and  characteristic.  A 
tumor  of  the  cardia  can  neither  be  felt  nor  seen.  Sometimes 
the  filled  esophageal  pouch  produces  dulness  posteriorly  to 
the  left  of  the  eighth  or  ninth  dorsal  vertebra.  Depression 
and  percussion  over  the  lower  end  of  the  sternum  are  some- 
times painful;  seldom  a  painful  pressure-point  exists  pos- 
teriorly and  to  the  left  of  the  ninth  dorsal  vertebra.  These 
are,  however,  only  suggestive  and  not  revealing  signs.  When 
the  stenosis  is  so  great  as  to  prevent  the  ingestion  of  enough 
food,  emaciation  and  loss  of  strength  develop.  If  water  also 
is  more  or  less  excluded,  the  inanition  becomes  more  marked, 
and  the  wasting  of  the  fat  and  muscles  may  become  extreme; 
there  may  be  great  prostration,  sunken  abdomen,  contracted 
stomach  and  intestines,  and  the  general  skeleton-like  appear- 
ance of  food-and-water  starvation.  The  quantity  of  urine 
passed  daily  is  a  fair  measure  of  the  degree  of  obstructive 
retention. 

The  swallowing  sounds  may  be  of  some  diagnostic  value. 
There  is  not  likely  to  be  a  stenosis  when,  after  a  swallow  of 
water,  the  first  and  second  sounds  are  both  heard,  separated 
by  an  interval  of  about  twelve  seconds.  If  obstruction  is 
present,  both  sounds  may  be  absent,  or  the  appearance  of  the 
second  sound,  which  marks  the  completion  of  the  passage  of 
the  water  swallowed,  may  be  delayed,  or,  if  the  esophagus 
contracts  with  little  force,  the  second  sound  may  be  inaudible. 
These  auscultation  signs  and  the  other  foregoing  physical 
signs  are  only  suggestive  or  presumptive. 

The  characteristic  physical  sign  is  obtained  by  sounding 
the  esophagus.  This  should  first  be  attempted  with  the 
stomach-tube,  using  various  sizes.  For  this  purpose  a  tube 
with  a  single  side-eye  near  the  extremity  is  preferable,  inas- 
much as  it  makes  it  possible  to  locate  and  to  measure  the 
length  of   the  stenosis  more  exactly.     If  the  eye  be  above 


OBSTRUCTION   OF   THE    ORIFICES.  58 1 

the  stricture,  only  a  little  water  can  be  introduced,  and  this 
can  be  removed  by  siphonage.  If  the  eye  be  beyond  the 
obstruction,  the  water  passes  into  the  stomach.  If  the  eye  is 
within  the  stomach,  the  introduced  water  can  be  removed  by 
expression.  The  stricture  of  the  cardia  thus  located  and  its 
length  measured  (provided  it  can  be  passed),  is  about  40 
cm.  from  the  point  where  the  incisor  teeth  touch  the  intro- 
duced sound.  The  solid,  flexible,  black-rubber  esophageal 
sounds  may  also  be  employed  to  detect  and  measure  the 
distance  of  the  stricture  from  the  incisor  teeth.  The  olive- 
pointed  bougies  are  dangerous. 

A  piece  of  the  tumor  may  be  sometimes  withdrawn  in  the 
eye  of  the  stomach-tube.  Blood  is  more  likely  to  be  obtained 
when  the  obstruction  is  due  to  cancer,  and  the  substances 
withdrawn  on  or  in  the  tube  in  malignant  disease  are  some- 
times of  a  foul  odor.  These  anatomical  signs,  which  reveal 
the  malignant  nature  of  the  obstruction,  are  obtained  fre- 
quently enough  to  attract  and  deserve  attention. 

Diagnosis. — The  diagnosis  is  easy  if  the  clinical  history  be 
sufficiently  clear  to  suggest  the  use  of  the  sound,  and  if  the 
latter  be  found  to  meet  with  resistance  about  40  cm.  from 
the  incisor  teeth.  The  slight  normal  resistance  of  the  cardia 
to  the  passage  of  the  sound  will  produce  no  suspicion  in  the 
mind  of  one  with  some  experience  in  the  use  of  this  instru- 
ment. Other  symptoms  and  signs  may  suggest  the  situation 
of  the  trouble.  But,  unfortunately,  in  the  early  stage  the 
sensations  of  the  patient,  and  particularly  his  description 
of  them,  are  somewhat  vague.  The  patient  may  only  com- 
plain of  a  little  shortness  of  breath,  fullness  and  oppression  in 
the  chest,  a  slight  irregularity  or  rapidity  of  the  heart's  action, 
and  pain,  which  is  particularly  excited  by  exercise,  and  which 
disappears  after  a  few  moments  in  spite  of  the  continuance  of 
the  exercise.  The  layman  is  most  likely  to  be  anxious  about 
his  heart,  and  to  have  this  organ  in  his  mind,  often  denying  any 
difficulty  in  swallowing,  as  there  is  no  pharyngeal  trouble.  "  I 
fear  my  heart  is  diseased  ;  I  care  nothing  about  the  regurgita- 
tions and  other  dyspeptic  symptoms,"  is  a  statement  some- 
what frequently  made  in  this  early  stage.  A  history  of  this 
kind  should  direct  the  attention  of  the  physician  to  the  cardia. 

After  the  certainty  of  the  existence  of  an  obstruction  of 
the  cardia  is  established,  the  detection  of  its  cause  is  practi- 
cally very  important,  and  sometimes  difficult.  Particular 
attention  should  be  given  to  the  evolution  and  persistence  of 
the  symptoms  and  to  the  character  of  the  signs.  Is  the 
stricture  organic,  and.  if  so,  what  is  its  nature? 


582  DISEASES  OF  THE  STOMACH. 

Spasmodic  stricture  of  the  cardia  occurs  chiefly  in  neuro- 
paths. It  is  most  common  in  neurasthenic  or  hysterical  girls, 
about  the  age  of  puberty,  and  in  women  during  the  meno- 
pause. Men,  particularly  of  the  arthritic  types,  are  by  no 
means  exempt.  But  a  favorable  temperament  or  constitution 
can  only  excite  suspicion  of  the  spasmodic  nature  of  the 
stricture.  There  are,  however,  three  cardinal  and  pathogno- 
monic signs  :  the  obstruction  is  intermittent ;  a  large  sound 
passes  as  readily  as  a  small  one  after  both  have  been  arrested 
(gentle  and  sustained  pressure  is  often  sufficient  to  overcome 
the  resistance) ;  and  antispasmodics  relieve  the  obstruction. 
If  the  stomach-tube  does  not  pass  after  gentle  and  prolonged 
pressure,  and  if  no  anatomical  signs  are  obtained  upon  its 
withdrawal,  the  patient  should  be  quickly  put  under  the  influ- 
ence of  the  bromids.  The  spasm  will  then  relax,  and  no 
obstacle  will  be  encountered  in  passing  the  tube.  To  avoid 
repetition,  the  reader  is  referred  for  other  distinctive  signs  to 
the  article  on  Spasm  of  the  Cardia. 

The  cause  of  the  organic  stricture  is  determined  by  exclu- 
sion. The  age  of  the  patient,  the  duration  of  the  trouble, 
and  the  signs  of  a  disease  likely  to  cause  obstruction,  all 
have  a  differential  value.  If  a  corrosive  poison  has  been 
swallowed,  or  if  the  esophagus  has  been  burned  by  hot  food 
or  water,  or  if  there  have  been  symptoms  and  signs  of  an 
ulcer,  the  stenosis  is  most  probably  cicatricial.  In  the  absence 
of  such  a  history,  the  obstruction  is  most  probably  cancerous, 
particularly  if  there  are  other  constitutional  and  local  signs  of 
malignant  disease  and  if  no  disease  which  is  likely  to  com- 
press the  digestive  tube  at  this  point  can  be  discovered. 

Prognosis. — The  prognosis  is  dependent  on  the  nature  and 
degree  of  the  stenosis.  The  auto-intoxication  and  inanition 
of  carcinoma  prove  fatal  in  five  or  six  months.  Cicatricial 
stenosis,  after  the  scar  tissue  has  finished  contracting,  and 
when  the  stricture  is  of  large  caliber,  may  permit  the  main- 
tenance of  nutrition  by  careful  alimentation.  Even  a  cica- 
tricial stricture  of  small  caliber  leaves  room  for  some  hope  of 
relief  by  surgical  treatment.  The  prognosis  is  never  good 
and  should  always  be  guarded. 

Treatment. — The  treatment  consists  in  appropriate  alimenta- 
tion, so  as  to  maintain,  as  long  as  possible,  the  balance  of 
nutrition,  the  control  of  fermentation  and  putrefaction  when 
they  exist,  the  protection  of  the  diseased  part  against  in- 
jurious irritation,  and  the  employment  of  surgical  procedures 
to   increase  the  caliber  of  the  stricture,  to   maintain   its  per- 


OBSTRUCTION  OF   THE    ORIFICES.  583 

meability,  or  to  form  an  artificial  gastric  fistula  through  which 
the  patient  can  be  fed. 

The  two  important  qualities  of  the  food  are  its  nutritive 
value  and  its  power  to  pass  the  obstruction.  The  caliber  of 
the  stricture  has  the  most  to  do  with  the  selection  of  the  diet. 
So  long  as  there  is  present  an  active  inflammation  or  excess- 
ive irritability,  the  food  should  be  warm,  fluid,  and  unirritating, 
so  as  not  to  increase  the  swelling  nor  to  excite  spasm.  The 
artificially  digested  foods  possess  no  advantages  over  the  fresh 
fluid  preparations.  Milk,  raw  eggs,  expressed  meat  juice,  the 
juice  of  the  grape  and  pineapple,  and  of  other  unirritating 
and  nutritious  fruits,  meat  powder,  cocoa,  chocolate,  and 
similar  fluid  preparations  suitable  to  the  digestive  power 
and  nutritive  state  of  the  individual  patient  should  be  ord- 
ered. Nutrient  enemata  should  be  employed  as  soon  as 
alimentation  by  the  mouth  is  insufficient. 

When  stagnation  and  retention  are  present,  fermentation 
and  putrefaction  may  be  distressing  and  injurious.  The 
mouth,  nose,  and  throat  should  be  kept  as  sweet  as  possible. 
A  little  brandy  may  be  given  from  time  to  time  with  advan- 
tage, and  the  least  irritating  antiseptics  may  be  tried.  If  the 
esophageal  pocket  is  large  and  retention  is  present,  the  con- 
tents should  be  withdrawn  before  fermentation  becomes 
active,  and  the  cavity  should  be  washed  out  with  warm 
Thiersch's  solution.  Methylene-blue  may  be  used  when  the 
stricture  is  cancerous,  or  the  iodid  of  sodium  and  arsenic 
may  be  prescribed  (Boas).  Codein  may  be  required  to 
relieve  pain  or  spasm  of  the  cardia. 

The  surgical  procedures  are  numerous.  In  cicatricial 
stenosis  gradual  dilatation  with  flexible  rubber  esophageal 
sounds  or  more  rapid  dilatation  with  the  balloon  catheter  may 
be  undertaken.  This  treatment  maybe  employed  early,  while 
the  stricture  is  of  large  caliber,  and  should  be  conducted 
on  the  same  principles  as  the  gradual  dilatation  of  a 
urethral  stricture.  If  the  cicatricial  stenosis  is  impermeable, 
or  if  its  caliber  is  so  small  as  to  prevent  the  ingestion  of  suffi- 
cient food,  gastrostomy  may  be  performed  and  an  effort  may 
be  made  to  dilate  the  stricture  from  the  stomach,  with  a  view 
to  continuing  the  dilatation  later  by  the  mouth.  In  the 
meantime  the  patient  should  be  fed  through  the  fistulous 
opening.  Sometimes  the  stomach  is  so  small  and  lies  so 
deep  that  gastrostomy  is  impracticable.  Jejunostomy  should 
then  be  performed  instead. 

In  cancerous  obstruction  gradual  dilatation  can  serve  no 
purpose.     When  the  quantity  of  food  introduced  by  mouth 


584  DISEASES  OF  THE  STOMACH. 

and  rectum  is  so  small  as  to  entail  rapid  emaciation  and  loss 
of  strength,  gastrostomy  may  be  performed,  but  with  little 
hope  of  prolonging  life  or  of  diminishing  the  discomfort. 

2.  Obstruction  of  the  Pylorus — Pyloric  obstruction  is 
usually  described  among  the  causes  of  "dilatation"  of  the 
stomach.  It  is  true  that  pyloric  obstruction  may  eventually 
produce  enlargement  of  the  stomach  ;  but  the  disease  should 
not  be  named  after  one  of  its  final  effects,  for  practically  and 
essentially  the  trouble  is  the  obstruction.  The  word  "  ob- 
struction," however,  does  not  cover  the  whole  period  of  the 
genesis  and  evolution,  for  before  the  beginning  of  the  obstruc- 
tion there  may  have  been  some  inflammatory  or  ulcerative 
process  or  some  local  nutritive  or  developmental  trouble. 
But  whether  the  obstruction  be  a  complication  or  a  sequel, 
congenital  or  neoplastic,  a  new  danger  is  added,  and  the 
clinical  picture  and  treatment  are  changed  by  it.  It  becomes 
practically  a  morbid  process,  enforcing  changes  and  conse- 
quences manifested  by  a  group  of  symptoms.  Nor  does  the 
disease  begin,  as  is  often  tacitly  assumed,  with  "  dilatation." 
The  final  period  of  gastric  retention  is  preceded  by  periods 
of  compensation  and  of  stagnation. 

Neither  is  pyloric  obstruction  synonymous  with  obstruc- 
tion to  the  evacuation  of  the  stomach,  for  stagnation  and 
retention  are  frequently  caused  by  duodenal  obstruction. 
These  two  symptoms  (stagnation  and  retention)  may  be  pro- 
duced by  myasthenia,  by  supersecretion,  by  pyloric  obstruc- 
tion, and  by  duodenal  obstruction.  Pyloric  obstruction 
is  a  result  or  accompaniment  of  a  number  of  distinct  dis- 
eases of  the  stomach,  which  are  of  the  very  greatest  medical 
and  surgical  interest.  Its  forms  should  be  differentiated  and 
carefully  studied,  with  a  view  to  their  recognition  when  met 
with  at  the  bedside. 

Etiology. — Pyloric  obstructi9n  may  be  either  organic  or 
due  to  spasm  of  the  pyloric  muscle.  The  spasmodic  form  is 
described  in  Section  iv. 

Congenital  atresia  of  the  pylorus  is  very  rare,  but  is  more 
common  than  the  same  defect  of  the  cardia.  The  digestive 
tube  may  be  represented  at  this  point  by  a  fibrous  cord,  or, 
more  frequently,  the  canal  is  not  completely  obliterated,  but 
is  of  small  caliber.  The  development  of  the  pylorus  may  be 
arrested  at  any  stage,  and  the  infant  may  die  of  inanition  a 
short  period  after  birth  or  may  grow  into  manhood  by 
observance  of  a  suitable  diet. 


OBSTRUCTION  OF   THE    ORIFICES.  585 

Another  cause  of  pyloric  obstruction  is  cellulomuscular 
hypertrophy  and  hyperplasia.  The  increase  in  size  may  be 
so  great  as  to  present  a  veritable  tumor,  consisting  of  a  large 
number  of  circular  muscular  fibers  and  increased  submucous 
connective  tissue.  This  benign  hypertrophy  of  the  pylorus 
is  of  two  distinct  varieties — simple  and  inflammatory.  The 
simple  hypertrophy  is  of  a  purely  functional  or  nutritive 
nature.  The  inflammatory  hypertrophy  or  the  hyperplasia 
is  a  sequel  of  chronic  hypersthenic  gastritis,  the  lumen  being 
made  smaller  by  hyperplastic  thickening  of  the  pyloric  wall. 
The  productive  inflammation  and  hyperplasia  involve  the 
mucosa,  the  submucosa,  and  the  muscular  layer. 

Very  seldom  the  pylorus  is  obstructed  by  a  foreign  body. 
This  may  be  produced  by  a  wandering  gall-stone,  a  gas- 
trolith,  or  a  swallowed  foreign  body  which  has  obtained 
lodgment  in  the  pylorus. 

Obstruction  by  a  benign  tumor  is  also*  very  rare.  The  ob- 
structing tumor  may  develop  in  the  gastric  wall  close  to  the 
pylorus,  or  the  canal  may  be  closed  by  a  polyp  becoming  en- 
gaged in  it. 

Syphilitic  and  tubercular  ulceration  is  scarcely  known  at 
this  point  of  the  digestive  tube.  More  frequently  the  pylorus 
is  obstructed  by  the  contraction  of  the  scar  tissue  resulting 
from  the  destructive  action  of  chemical  poisons. 

The  pylorus  is  sometimes  compressed  by  a  tumor  develop- 
ing in  its  vicinity,  or  by  a  gall-stone  in  the  common  bile 
duct,  or  by  constricting  bands  of  fibrous  tissue  resulting  from 
peritonitis,  or  by  displacements  of  the  stomach.  Obstruction 
of  the  duodenum,  however,  is  more  frequently  thus  pro- 
duced. 

Ulcer  is  one  of  the  common  causes  of  pyloric  obstruction. 
During  the  evolution  of  the  ulcer  the  obstruction  may  be 
due  to  the  inflammatory  swelling  and  thickening  of  the  walls 
of  the  ulcer  or  to  pyloric  spasm.  More  frequently  the  ob- 
struction is  due  to  the  deformity  produced  by  contraction  of 
the  ulcer  scar. 

The  most  common  cause  of  pyloric  obstruction  is  undoubt- 
edly cancer.  Here  the  location  and  direction  of  the  growth 
of  the  neoplasm  are  more  important  than  its  size.  The  car- 
cinoma is  very  often  a  small  annular  scirrhus. 

Clinical  Description. — Pyloric  obstruction  presents  three 
stages — the  periods  of  compensation,  of  stagnation,  and  of  re- 
tention. The  duration  of  these  periods  is  dependent  on  the 
nature  and  rapidity  of  the  development  of  the  obstruction 
and    the    readiness    with    which    the    muscular    layer  of  the 


586  DISEASES  OF  THE  STOMACH. 

Stomach  undergoes  compensatory  hypertrophy,  which  may 
more  than  double  tlie  thickness  of  the  stomach  wall.  The 
hypertrophic  thickenini^  is  always  greatest  near  the   pylorus. 

The  period  of  compensation  is  characterized  clinically  by 
the  very  great  disturbances  produced  by  dietetic  excesses, 
particularly  the  eating  of  large  quantities  of  coarse  food.  The 
muscular  hypertrophy  compensates  only  on  condition  that  the 
stomach  is  not  given  too  much  mechanical  work  to  do.  A 
small  meal  that  is  hnel)'  subdivided  by  proper  preparation 
and  thorough  mastication  will  be  comfortably  digested.  Even 
a  large  meal  of  the  same  character  may  be  digested  and  evacu- 
ated by  the  stomach  without  perceptible  trouble.  Fluids  are 
more  readil)' evacuated  than  solids.  During  the  active  period 
of  gastric  digestion  the  stomach  can  be  felt  periodically  con- 
tracting. All  these  characteristics  are  absent  in  myasthenia, 
with  which  pyloric  obstruction  is  often  confounded.  But  a 
large  meal  composed  of  coarse,  solid  food,  made  excitant  by 
condiments,  produces  stormy  peristalsis,  colic,  and  often  vomit- 
ing. The  vomit  is  alimentary,  often  contains  but  little  fluid, 
and  is  frequently  excessively  acid,  not  from  fermentation,  but 
from  secretory  irritation.  The  active  churning  movements, 
and  the  intermittent  and  somewhat  accidental  damming  of 
the  current,  are  unfavorable  to  germ  growth.  The  period 
of  compensation,  marked  clinically  by  recurring  attacks  of 
motor  disturbance  produced  in  a  particular  manner,  may  be 
long  or  very  short.  In  benign  hypertrophy  of  the  pylorus,  in 
congenital  stenosis  of  large  caliber,  and  in  moderate  cicatricial 
obstruction,  compensation  may  continue  for  years.  Pyloric 
spasm  may  play  an  important  part  in  the  development  of  the 
attacks,  particularly  when  an  inflamed  ulcer  is  located  near 
the  pylorus.  The  period  is  usually  very  short  in  obstructing 
carcinoma,  in  cases  of  ulcer  which  rapidly  close  the  canal, 
and  in  severe  cases  of  ulceration  or  of  corrosive  to.xic  gas- 
tritis. 

The  period  of  stagnation  may  mark  either  the  beginning 
of  the  obstruction  or  the  beginning  of  failure  of  compensa- 
tion. The  stomach  empties  itself  slowly,  and  never  contains 
in  the  morning  before  breakfast,  as  it  does  in  retention, 
food  which  was  eaten  the  evening  before.  Delay  in  the 
evacuation  of  the  stomach,  which  is  one  of  the  signs  of 
functional  stagnation,  may  be  but  slight,  or,  in  the  severe 
cases,  the  stomach  may  be  found  empty  at  only  one  period 
during  the  twenty-four  hours,  this  being  in  the  earh'  morning, 
during  the  long  interval  between  the  evening  meal  and  break- 
fast.    The  stomach   trouble   may  manifest  itself,  in   the  same 


OBSTRUCTION   OF   THE    ORIFICES.  587 

manner  as  in  the  first  stage,  only  during  accidental  failure  of 
compensation  ;  or  the  stagnation  may  produce  symptoms  after 
each  meal.  The  irritation  may  not  be  sufficient  to  cause  much 
disturbance  after  breakfast,  but  when  the  stomach  does  not 
empty  itself  between  breakfast  and  the  evening  meal,  there  may 
result  an  accumulative  effect  manifesting  itself  each  afternoon 
or  evening.  The  irritation  of  the  fermenting  contents  and  the 
excessively  acid  secretion  may  produce,  particularly  in  the  cica- 
tricial stenosis  of  ulcer,  intolerance  of  food  by  the  stomach  and 
a  rebellious  form  of  alimentary  vomiting.  The  vomit  contains 
food  mixed  with  a  clear,  acid  fluid  holding  a  large  quantity 
of  albumoses  in  solution.  When  no  compensatory  hyper- 
trophy has  developed  there  may  result  an  asthenic  state, 
with  a  sensation  of  weight,  with  belching,  and  with  acid 
regurgitations,  particularly  in  carcinoma.  Pain,  and  some- 
times very  severe  pain,  is  likely  to  be  a  symptom  of  the 
stagnation.  Emaciation,  but  often  very  slight,  occurs  even 
in  the  mild  cases  ;  and  when  the  stagnation  leads  to  gastric 
intolerance,  inanition  develops  rapidly.  This  stage,  also, 
according  to  the  rapidity  of  the  evolution  of  the  causative 
disease  may  be  either  long  or  short. 

Retention,  or  the  third  period,  is  characterized  by  the  failure 
of  the  stomach  to  evacuate  its  contents  at  any  time  during  the 
twenty-four  hours,  by  copious  vomiting  of  accumulated  foods 
and  large  quantities  of  fluid  and  digestive  products,  and  by 
more  active  fermentation  with  gas  formation.  Pain,  as  in 
stagnation,  not  only  encroaches  on  the  period  of  normal  gas- 
tric repose,  but  also  often  continues  throughout  that  period. 
The  symptoms  due  to  the  absorption  of  an  insufficient  quan- 
tity of  nutriment  and  water  are  combined  with  those  of 
gastric  auto-intoxication.  Emaciation  and  loss  of  strength 
may  be  very  great,  and  the  patient  may  become  markedly 
cachectic.  This  stage  may  result  from  the  obstruction 
becoming  greater  and  greater  or  from  the  failure  of  the  mus- 
cular layer  of  the  stomach  to  maintain  compensation. 

Congenital  atresia  proves  rapidly  fatal.  The  infant  may  be 
well  enough  at  birth,  but  uncontrollable  vomiting  soon  begins, 
and  death  follows  without  any  food  or  drugs  ever  having 
passed  through  the  alimentary  canal. 

Congenital  stenosis  produces  symptoms  which  depend  upon 
the  caliber  of  the  stricture.  If  the  canal  be  very  small,  the 
stomach,  after  enlarging,  and  without  undergoing  hyper- 
trophy, becomes  intolerant,  and  death  results  in  a  few  months 
from  inanition.  If  the  caliber  be  larger,  the  stomach  increases 
in  size  and  strength,  and  compensation   may  be  established. 


588  DISEASES  OF  THE  STOMACH. 

At  no  time  is  there  a  {)alpable  pyloric  tumor,  and  the  symp- 
toms of  obstruction  be^in  soon  after  birth.  These  children 
with  large  and  hypertrophied  stomachs  are  in  constant  danger 
of  the  failure  of  compensation  and  the  development  of  reten- 
tion. The  obstruction  becomes  uncompensated  during  each 
attack  of  a  severe  acute  disease,  and  adds  largely  to  the 
danger. 

Simple  benign  hypertrophy  of  the  pylorus  is  produced  in 
two  ways.  The  one  is  functional  and  nutritive,  and  develops 
and  produces  obstruction  in  the  same  manner  that  the  strong 
and  irritable  anal  sphincter  causes  constipation.  The  other  is 
due  to  duodenal  stenosis,  the  pyloric  ring  developing  so  as  to 
aid  in  establishing  compensation  and  prevent  the  reflux  of 
the  contents  of  the  duodenum  into  the  stomach.  In  the  first 
form  gastric  compensation  may  be  complete.  In  the  second, 
compensatory  hypertrophy  of  the  muscular  layer  of  the 
stomach  is  maintained  with  greater  difficulty,  and  the  stomach 
may  often  contain  bile  and  pancreatic  juice,  the  expressed 
contents  after  being  rendered  alkaline,  digesting  albumin,  and 
also  emulsifying  oil.  Benign  hypertrophy  may  present  in  its 
evolution  the  three  stages  of  compensation,  stagnation,  and 
retention.  The  disease  usually  develops  slowly,  and  often 
lasts  a  number  of  years. 

The  clinical  expression  varies  little,  whether  the  hyper- 
trophy be  functional  and  nutritive  or  the  result  of  hyper- 
sthenic gastritis.  The  three  clinical  periods  are  well  marked, 
and  the  duration  of  the  disease,  which  is  frequently  fatal,  is 
long.  During  the  first  period  the  accidental  disturbances 
of  compensation  produce  the  morbid  features,  the  intervals 
between  them  being  symptomless.  These  recurring  attacks, 
produced  by  dietetic  excesses  or  errors,  may  be  short  or  may 
last  one  or  two  weeks.  Three  or  four  hours  after  the  exces- 
sive meal  gastric  pain  commences,  increases  in  severity,  and 
is  greatly  relieved  by  the  vomiting  which  ensues,  the  charac- 
teristics of  which  demonstrate  the  stagnation  of  the  food  in  the 
stomach.  The  vomit  contains  food,  often  a  good  deal  more 
fluid  than  was  swallowed,  and  is  excessively  rich  in  hydro- 
chloric acid  and  mucus.  After  the  vomiting  the  pain  sub- 
sides, and  the  following  meal  may  be  evacuated  properly, 
demonstrating  the  reestablishment  of  compensation.  The 
attacks,  however,  may  last  a  week  or  two,  and  during  this 
period  the  pain  varies  in  intensity,  often  completely  subsiding 
for  a  ^Qv/  hours.  The  vomiting  occurs  soon  after  a  meal  of 
solid  or  liquid  food,  or  later,  at  the  time  when  the  stomach 
should  normally  be  empty.     The  bowels  are  obstinately  con- 


OBSTRUCTION  OF   THE    ORIFICES.  589 

stipated.  These  attacks  may  recur  after  an  intermission  of 
weeks,  or  even  months. 

During  the  period  of  severe  stagnation  the  manifestations 
are  more  continuous,  and  pain  is  likely  to  recur  after  each 
meal,  in  relation  with  the  evolution  of  secretion  and  the 
activity  of  peristalsis.  The  gastritis  is  increased  by  the  irri- 
tation of  the  acid  contents,  which  remain  abnormally  long  in 
the  stomach.  The  stomach  may  become  intolerant,  or  vomit- 
ing may  occur  only  once  or  twice  in  the  twenty-four  hours. 
Constipation  is  obstinate.  The  pylorus  is  exceedingly  sen- 
sitive, and  both  anteriorly  and  posteriorly  pain  upon  pressure 
is  marked,  and  extends  over  a  large  area. 

When  retention  begins,  the  clinical  picture  changes.  The 
vomiting  is  copious  and,  usually,  less  frequent.  The  pain  is 
very  severe,  and  may  continue  day  and  night.  Liquids  as 
well  as  solids  are  retained  too  long  in  the  stomach.  The 
vomit  is  liquid,  separates  into  three  layers,  and  contains  pro- 
ducts of  hydrochloric-pepsin-digestion,  and  organic  acids. 
Gas-formmg  fermentation  is  active  in  the  tube-tests.  The 
bowels  are  obstinately  constipated,  and  the  quantity  of 
urine  is  small,  constituting  a  rough  measure  of  the  degree  of 
stenosis.  The  appetite  is  now  lost  and  the  emaciation  may 
become  cachectic.  Death  follows  from  inanition  and  auto- 
intoxication. 

Obstruction  by  benign  tumors  is  exceedingly  rare,  and  pre- 
sents, like  syphilitic  and  tubercular  ulceration,  no  distinctive 
clinical  expression.  Toxic  gastritis  more  frequently  produces 
obstruction  of  the  cardia  than  of  the  pylorus.  The  develop- 
ment of  the  usual  signs  of  pyloric  obstruction  after  the  swal- 
lowing of  a  corrosive  chemical  reveals  the  character  of  the 
trouble.  The  stenosis  may  be  of  large  caliber  or  may  pro- 
duce complete  occlusion.  The  strictures  of  large  caliber 
present  a  period  of  stagnation  or  retention,  and  may  become 
compensated  by  gastric  hypertrophy  after  a  few  weeks.  The 
compensatory  hypertrophy  produces  the  only  improvement, 
cicatricial  stenosis  being  permanent  and  the  contraction  of 
the  scar  tissue  being  often  rapid. 

The  stenosis  of  ulcer  may  occur  during  the  evolution  of 
the  ulcer,  or  during  or  after  its  healing.  If  it  occur  from 
inflammatory  swelling  during  the  period  when  the  ulcer  is 
still  progressive,  gastric  intolerance  is  rapidly  developed. 
The  vomiting  usually  occurs  in  from  one-half  to  two  or  three 
hours  after  the  meal,  and  often  contains  food  eaten  eight  or 
ten  hours  previously.  The  development  of  obstruction 
changes  the  clinical  expression  of  ulcer — the  pain  increases, 


590  DISEASES  OF  THE  STOMACH. 

vomiting  becomes  more  obstinate,  emaciation  is  rapid,  and, 
with  tlie  stagnation  and  retention,  fermentation  also  sets  in, 
and  is  in  no  manner  prevented  by  the  excessively  acid  secre- 
tion. The  obstruction  may  begin  as  the  ulcer  commences  to 
heal,  and  its  development  is  then  commonly  preceded  by  a 
period  of  improvement.  The  cardinal  symptoms  of  ulcer, 
with  the  exception  of  hemorrhage,  increase,  those  of  obstruc- 
tion develop,  and  the  hypersthenic  gastritis  becomes  more 
active.  But  more  frequently  obstruction  develops  after  the 
ulcer  has  healed.  Recovery  has  been  marked  by  the  cessa- 
tion of  all  the  symptoms  of  ulcer,  the  scar  tissue  is  contract- 
ing, but  the  patient  again  becomes  ill,  and  the  signs  are  those 
of  obstruction  combined  with  hypersthenic  gastritis.  The 
cicatricial  stenosis  of  ulcer  may  present  the  three  periods  of 
compensation,  stagnation,  and  retention  ;  and  the  keynote  of 
the  clinical  expression  is  persistent  and  often  violent  pain. 

Cancerous  obstruction  is  the  most  frequent  form.  It  often 
develops  with  great  rapidity,  and  marks  a  turning-point  in 
the  clinical  history  of  carcinoma.  Stagnation  and  retention 
may  occur  in  cancer  from  the  loss  of  functional  activity 
of  the  muscular  layer.  But  when  obstruction  begins,  the 
denutrition  becomes  more  active,  vomiting  is  likely  to  be 
more  obstinate,  and  the  fermentation  generates  large  quanti- 
ties of  gas,  both  in  the  stomach  and  in  the  fermentation 
tube  tests. 

However  caused,  pyloric  obstruction  presents  three  degrees 
or  stages — compensation,  stagnation,  and  retention  ;  but  the 
clinical  expression  varies  in  relation  with  the  nature  of  the 
underlying  cause.  In  carcinomatous  obstruction  even  tem- 
porary compensation  is  exceedingly  rare. 

Symptomatology. — The  modifications  of  the  appetite  are 
dependent  on  many  features  of  the  disease.  In  the  later 
stages  the  state  of  nutrition  is  of  great  influence.  The  causa- 
tive disease  exerts  its  modifying  power.  Anorexia  is  com- 
mon in  carcinoma.  The  appetite  is,  on  the  other  hand,  well 
preserved  or  even  increased  in  benign  hypertrophy,  in  ulcer, 
and  in  hypersthenic  gastritis,  the  latter  being  sometimes  a 
cause  and  sometimes  a  sequel  of  the  pyloric  obstruction. 
Mental  and  moral  depression  and  nervous  weakness,  which  are 
sometimes  manifestations  of  pyloric  obstruction,  decrease  the 
appetite;  but  apart  from  the  state  of  nutrition  and  of  the 
nervous  system,  apart  from  the  nature  of  the  causative  dis- 
ease, and  in  the  absence  of  trouble  in  any  other  organ,  pyloric 
obstruction  modifies  the  appetite  by  the  gastric  fermentation, 
and  the  intestinal  putrefaction,  resulting  from  the  stagnation 


OBSTRUCTION   OF   THE    ORIFICES.  59 1 

and  retention.  The  appetite  diminishes  as  the  uncleanh'ness 
of  the  stomach  increases.  During  the  period  of  compensation 
the  appetite  is  good  and  there  is  no  excessive  thirst.  In 
stagnation  the  appetite  is  variable.  But  where  pronounced 
retention  exists,  the  appetite  is  Hkely  to  be  poor,  and  thirst 
may  be  unquenchable. 

Pain  is  one  of  the  most  common  local  symptoms,  and  is 
due  to  a  variety  of  circumstances.  It  may  be  due  to  ulcer, 
to  the  associated  hypersthenic  gastritis  and  excessive  secre- 
tion, or  to  fermentation.  This  form  of  pain  is  produced  by 
irritation,  and  may  be  made  severer  by  the  irritable  weakness 
of  the  nervous  system.  Another  cause  of  pain  is  the  peri- 
staltic effort  to  overcome  the  obstruction,  which  is  particularly 
marked  during  the  stages  of  compensation  and  stagnation. 
The  pain  of  retention  is  due  also  to  irritation.  The  little 
accidents  which  disturb  the  period  of  compensation  occur 
during  gastric  digestion,  the  peristaltic  effort  increasing  and 
becoming  painful  during  the  height  of  digestion  and  subsid- 
ing after  the  evacuation  of  the  stomach.  During  the  period 
of  stagnation  the  pain  is  both  peristaltic  and  irritative,  and 
may  occur  after  each  meal  or  only  after  the  heartiest  meal 
of  the  day.  It  ceases  with  the  evacuation  of  the  stomach. 
When  retention  begins,  the  pain  is  often  paroxysmal,  recurring 
once  or  twice  a  day  or  every  few  days.  In  other  cases, 
particularly  when  there  is  excessive  secretion,  the  pain  hardly 
ceases  day  or  night,  and  sometimes  is  intolerable. 

Vomiting  is  almost  as  frequent  as  gastric  pain.  During 
the  period  of  compensation  it  occurs  as  a  terminal  sign  of 
the  accidental  or  temporary  muscular  insufficiency.  It  then 
commonly  occurs  at  the  moment  when  the  contents  of  the 
stomach  should  already  have  been  evacuated  completely 
into  the  duodenum.  The  peristaltic  movements  become 
more  and  more  stormy,  and  are  usually  painful  until  the 
cardiac  orifice  is  forced  and  the  stomach  is  emptied  by 
vomiting.  This  form  of  vomiting  is  very  rare  in  myasthenia, 
but  may  occur  in  the  muscular  insufficiency  due  to  an  ex- 
cessive meal  or  to  nerve  or  muscle  fatigue.  The  vomit  which 
results  from  a  temporary  disturbance  of  compensation  is 
alimentary  and  contains  but  little  fluid.  During  the  period 
of  stagnation  vomiting  may  occur  a  little  later  than  the  time 
when  the  stomach  should  normally  be  empty,  either  after 
each  meal  or,  commonly,  only  once  or  twice  a  day,  and  as  the 
final  expression  of  an  attack  of  peristaltic  pain.  This  is  the 
period  when  vomiting  is  most  frequent  and  most  obstinate. 
The  stomach  often  becomes  for  a  few  days  completely  intol- 


59^  B/SEASES  OF  THE  STOMACH. 

erant,  and  both  fluids  and  solids  introduced  into  it  are  almost 
immediately  rejected.  The  stomach  is  completely  emptied. 
Nausea  is  common  during  and  after  these  attacks  of  intoler- 
ance, and  may  be  associated  with  an  almost  neutral  or  ex- 
cessively acid  gastric  juice.  Secretion  is  likely  to  be  very 
acid  during  the  period  of  intolerance  when  an  attempt  is 
made  to  feed  by  the  mouth,  and  there  is  then  a  good  deal  of 
pain  and  nausea.  But  after  the  force  of  the  attack  is  spent, 
and  even  while  the  stomach  is  given  functional  rest,  nausea 
is  prominent,  and  is  usually  accompanied  by  a  nearly  neutral 
secretion  and  by  occasional  vomiting.  The  vomiting,  except 
during  the  periods  of  intolerance,  is  not  immediate,  but  occurs 
only  a  long  time  after  meals.  The  vomit  is  alimentary, 
stagnant,  and  much  more  fluid  than  in  the  stage  of  com- 
pensation. The  period  of  stagnation  is  the  period  of  exces- 
sive formation  of  organic  acids,  and  butyric  acid  is  often  the 
cause  of  the  intolerance.  During  the  period  of  retention  the 
stomach  may  be  intolerant,  but  only  when  the  muscular 
layer  is  hypertrophied  and  irritable.  When  myasthenia 
develops,  the  stomach  yields  to  distention  without  a  struggle, 
and  the  vomiting  becomes  more  copious,  more  fluid,  and 
more  infrequent.  Once  every  few  days  vomiting  occurs, 
and  is  usually  effortless,  painless,  and  incomplete.  The 
stomach  does  not  completely  empty  itself.  This  is  the 
period  when  the  fermentation  tube  tests  yield  large  quantities 
of  gas  in  addition  to  organic  acids.  The  vomit  is  that  of  re- 
tention— overfermented,  acid,  fluid,  and  separating  on  stand- 
ing into  three  layers.  Many  constitutional  symptoms  and 
distant  effects  have  been  attributed  to  gastric  auto-intoxication. 
There  is  no  organ  of  the  body,  it  is  said,  which  may  not  be 
affected  by  toxic  products  absorbed  from  the  "dilated" 
stomach.  (This  theory  is  discussed  in  the  chapter  on  Myas- 
thenia Gastrica  and  in  the  section  on  the  Vicious  Circles  of 
the  Stomach.)  Many  of  these  accidents,  particularly  those 
which  involve  the  nervous  system,  are  seldom  observed  in 
pyloric  obstruction  not  complicated  by  intestinal  putrefaction. 
The  contents  of  the  stomach  are  neither  absorbed  nor  evacu- 
ated, to  a  noteworthy  extent,  into  the  intestines,  but  are 
periodically  removed  by  vomiting.  The  obstruction  protects 
both  the  intestines  and  the  system.  But  in  myasthenic 
retention  the  gateway  to  self-poisoning  remains  open.  Ob- 
structive retention  seldom  produces  melancholia,  hypochon- 
driasis, delirium,  hallucinations  of  sight,  diplopia,  hemianopia, 
formication,  cramps  in  the  extremities,  dyspnea,  tachycardia, 
arrhythmia,  irregularities    of  the    pulse,  acne,  urticaria,  ery- 


OBSTRUCTION   OF    THE    ORIFICES.  593 

thema  fugax,  and  other  disorders  of  the  nervous,  vascular, 
respiratory,  and  cutaneous  systems,  by  means  of  toxic  pro- 
ducts absorbed  from  the  stomach.  These  symptoms  are  more 
frequently  due  to  intestinal  toxemia,  but  indirectly  —  by 
mechanical  compression,  by  reflex  action,  and  by  inanition — 
obstructive  retention  may  exert  a  very  pernicious  influence 
on  the  various  functions.  The  enlarged  and  distended 
stomach,  filled  with  gas  and  acid  contents,  may  compress 
the  heart  and  limit  the  movements  of  the  diaphragm.  If  the 
fermentation  is  butyric,  acne  is  common  enough,  and  vaso- 
motor disorders  of  the  skin  may  likewise  be  produced  by 
the  reflexes  starting  from  the  irritated  gastric  mucous  mem- 
brane. Many  nervous  and  cardiorespiratory  symptoms 
may  be  induced  by  the  secondary  neurasthenia  and  anemia. 
Few  of  the  constitutional  symptoms  are  toxic,  but  some  un- 
doubtedly result  from  the  inanition.  The  skin  becomes  dry 
and  often  scaly,  the  extremities  cold,  and  the  body  a  more 
easy  prey  to  its  environment.  There  is  less  resistance  to 
bacterial  invasion  and  diminished  endurance  of  cold  weather 
and  of  sudden  atmospheric  changes.  The  voluntary  and  in- 
voluntary muscles  become  weak,  and  tonic  and  painful 
cramps  of  the  muscles  of  the  forearm  and  of  the  calves  of 
the  legs  are  not  rare.  But  these  symptoms,  with  emaciation 
and  loss  of  strength,  constipation,  and  diminution  of  urine, 
are  the  result  of  inanition.  The  food  and  water  are  retained, 
or  are  lost  largely  by  vomiting.  Water  may  be  eliminated 
in  large  quantities  by  excessive  gastric  secretion.  The  food, 
also,  instead  of  being  digested,  ferments  and  decomposes. 
The  result  is  a  form  of  starvation  accompanied  by  dry 
cachexia. 

The  nutritive  state  varies  in  the  different  stages  of  obstruc- 
tion, and  is  influenced,  also,  by  the  nature  and  evolution  of 
the  causative  disease.  In  the  cicatricial  stenosis  of  ulcer  and 
of  toxic  gastritis  the  patient  may,  in  the  beginning  of  the 
obstruction,  be  emaciated  and  anemic.  Cancer  also  pro- 
duces albuminous  denutrition  before  the  pyloric  canal  is 
obstructed  by  the  new  growth.  But,  apart  from  the  causa- 
tive disease,  pyloric  obstruction  affects  nutrition  in  proportion 
to  its  degree.  During  the  period  of  compensation,  on  a  suit- 
able diet  provided  it  be  supporting,  there  is  no  loss  of  weight 
or  of  strength.  But  when  compensation  fails  and  stagnation 
results,  nutrition  begins  to  suffer.  The  loss  of  weight  arid 
strength,  however,  during  this  period  is  due  more  to  acci- 
dents, particularly  fermentation  and  vomiting,  than  to  the 
obstruction,  for  the  stomach  eventually  empties  its  contents 
38 


594  DISEASES  OF  THE  STOMACH. 

into  the  intestines.  Wlien  retention  begins,  nutrition  fails 
more  rapidly,  and  the  body  is  not  only  insufficiently  nour- 
ished, but  excessively  dry.  When  the  retention  is  pronounced, 
the  patient  is  emaciated  and  the  skin  is  rough  and  dry.  The 
strength,  however,  often  does  not  fail  so  rapidly  as  might 
be  expected.  But  when  the  obstruction  is  cancerous,  or 
when  intestinal  auto-intoxication  exists  as  a  complication, 
the  muscular  weakness  develops  rapidly.  Suddenly  develop- 
ing obstruction  produces  more  rapid  and  complete  starvation 
than  results  from  any  other  disease  of  the  stomach. 

The  local  physical  signs  are  of  great  diagnostic  value. 
During  compensation  there  may  be  no  sign,  unless  a  tumor 
of  the  pylorus  can  be  felt.  But  after  meals  the  region  of 
the  normal  stomach  is  somewhat  prominent ;  the  stomach 
is  more  resistant  to  the  fingers,  and  its  form  is  well  preserved, 
particularly  during  digestion  ;  its  walls  feel  elastic  and  firmly 
contracted,  and  the  organ  may  be  enlarged.  If  the  abdominal 
wall  is  thin  and  yielding,  even  in  this  stage  the  strong  peri- 
staltic waves  are  sometimes  visible,  and  the  alternate  relaxa- 
tion and  contraction  of  the  stomach  are  often  palpable  at  the 
height  of  digestion.  During  the  period  of  stagnation  the 
peristalsis,  provided  the  stomach  is  not  myasthenic,  is  strong 
and  active,  and  is  more  likely  to  be  visible,  and  gastric  splash- 
ing may  be  elicited  at  the  time  when  the  stomach  is  inactive. 
But  visible  peristalsis  can  not  be  excited  in  the  empty  stomach 
in  the  morning  before  breakfast.  During  the  third  stage,  or 
that  of  retention,  two  physical  conditions  may  exist.  The 
stomach  may  be  strong  and  feel  firm  to  the  palpating  finger, 
and  the  splashing  sounds  may  be  elicited  with  greater  diffi- 
culty during  peristaltic  contraction  than  during  the  relaxation 
of  the  organ.  The  alternate  relaxation  and  contraction  may 
also  be  easily  felt ;  or,  on  the  other  hand,  the  stomach  may  be 
flabby  and  easily  compressible  during  its  contraction,  and 
the  splashing  sounds  may  be  produced  at  every  moment  with 
equal  ease.  In  both  conditions  gastric  splashing  is  absent  at 
no  time  during  the  twenty-four  hours,  and  the  abdominal 
wall  over  the  stomach  is  prominent,  except  when  the  organ 
is  emptied  by  the  tube  or  by  vomiting,  and  becomes 
more  and  more  prominent  as  the  stomach  fills  by  accumula- 
tion. The  comparatively  empty  and  contracted  intestines 
usually  occupy  but  little  space,  and  the  stomach  is,  as  a  rule, 
increased  in  size,  and  contains  a  large  quantity  of  gas  when, 
physiologically,  it  should  be  retracted  and  empty. 

A  palpable  tumor  of  the  prjHorus  is  a  valuable  sign  of 
pyloric  obstruction.     Such  a  tumor  may  be  formed  by  a  neo- 


OBSTRUCTION  OF   THE    ORIFICES.  595 

plasm,  by  an  ulcer  with  infiltrated  walls,  or  by  simple  or 
inflammatory  hypertrophy.  To  detect  the  tumor,  the  exami- 
nation should  be  made  when  the  stomach  is  empty  and  with 
the  patient  on  his  back.  When  the  tumor  lies  beneath  the 
false  ribs  it  may  sometimes  be  caught  by  the  fingers  at  the 
end  of  a  deep  inspiration,  particularly  if  the  patient  lies  on 
the  left  side.  Sometimes  the  tumor  can  be  felt  only  when  the 
stomach  is  moderately  filled  with  gas,  and,  consequently,  infla- 
tion may  aid  in  locating  the  tumor.  The  pyloric  tumor  can 
sometimes  be  felt  relaxing  and  contracting,  and  gas  can  be 
felt  and  heard  bubbling  through  it  synchronously  with  the 
peristaltic  contraction  of  the  stomach.  But  the  absence  of  a 
tumor,  even  when  the  pylorus  can  be  felt,  does  not  exclude 
pyloric  obstruction  from  arrested  development  and  cicatricial 
stenosis.  A  small  annular  scirrhus  produces  little  increase  in 
the  size  of  the  pylorus,  and  the  obstructing  tumor  may  be  out 
of  reach.  Frequently  enough,  neither  the  pylorus  nor  a 
pyloric  tumor  can  be  felt. 

The  functional  signs  vary  according  to  the  nature  and 
degree  of  obstruction  and  of  muscular  insufficiency,  the  char- 
acter of  the  contents,  and  the  form,  extent,  and  degree  of  the 
inflammation  of  the  mucous  membrane.  (The  functional  signs 
of  cancer,  of  ulcer,  and  of  hypersthenic  and  asthenic  gastritis 
are  described  in  the  chapters  on  these  diseases.)  Only  the 
functional  signs  due  solely  to  the  obstruction  need  here  receive 
attention.  During  the  stage  of  compensation  the  obstruction 
causes  no  abnormalities  in  the  digestion  and  evacuation  of  the 
test-breakfast  and  the  test-dinner.  Only  when  coarse,  solid 
food  is  given  is  the  evacuation  of  the  stomach  delayed.  During 
the  stage  of  stagnation  the  contents  remain  too  long  in  the 
stomach.  This  is  true  both  of  the  test-breakfast  and  the  test- 
dinner,  and  of  other  meals  containing  much  solid  food.  But 
a  glass  of  water  is  evacuated  as  readily  as  in  health,  and  this 
is  a  differential  sign  between  obstructive  and  myasthenic 
stagnation.  After  a  test-meal  less  fluid  is  withdrawn  than  in 
myasthenia.  The  stagnation  may  be  of  the  first  degree,  the 
stomach  emptying  itself  after  each  meal,  but  later  than  in 
health  ;  or  of  the  second  degree,  the  stomach  being  empty 
only  in  the  morning  before  breakfast.  During  the  stage  of 
retention,  the  stomach  is  never  empty  at  any  moment  during 
the  twenty-four  hours.  Even  if  the  stomach  be  washed  out 
in  the  evening,  before  the  Boas  supper  is  given,  on  the  follow- 
ing morning  it  will  be  found  to  contain  a  noteworthy  quantity 
of  food,  and  this  is  the  pathognomonic  sign  of  retention.  In 
obstructive  stagnation  and  retention  the  evolution  of  the  diges- 


59^  DISEASES  OE  THE  STOMACH. 

tion  of  the  test-breakfast  is  abnormal.  Not  only  is  digestion 
prolonged, — as  occurs  in  obstruction,  in  myasthenia,  in  hyper- 
chylia  gastrica,  and  in  hypersthenic  gastritis, — but  the  lines 
which  represent  the  evolution  of  the  total  acidity  of  the  free 
and  of  the  combined  HC1  show  sudden  rises  and  falls,  which 
are  due  to  the  irregularity  in  the  evacuation  of  the  contents 
of  the  stomach.  Clinically,  two  conditions  present  themselves 
in  obstructive  retention,  accordingly  as  the  muscular  layer  is 
strong  or  weak.  In  the  one,  if  the  stomach  be  washed  out, 
two  glasses  of  water  will  be  evacuated  within  one  and  one- 
half  hours,  as  revealed  by  the  cessation  of  splashing  or 
by  the  failure  to  express  anything  through  the  tube  or  to 
detect  anything  in  the  stomach  by  employing  a  one  per 
cent,  solution  of  sugar.  If  the  stomach  fails  to  stand 
this  test,  myasthenia  is  not  necessarily  present,  but  either 
the  obstruction  is  great  or  the  muscle  is  weak.  If  there  is 
retention  in  the  morning,  after  the  Boas  supper  has  been 
given  on  the  preceding  evening  on  a  clean  and  empty 
stomach,  and  if  a  pint  of  water  is  evacuated  within  one  and 
one-half  hours,  there  is  obstruction,  and  to  that  the  reten- 
tion is  solely  due.  In  the  other  condition  there  is  also  mus- 
cular weakness,  and  the  water  is  retained  much  longer  when 
given  in  the  same  manner. 

A  characteristic  of  the  contents  of  the  stomach  in  reten- 
tion is  the  separation  on  standing  into  three  layers,  on 
account  of  the  gas-forming  fermentation — the  upper  layer 
being  cloudy  and  frothy  ;  the  middle,  clear  and  fluid  ;  and  the 
lower,  sedimentary.  The  contents  withdrawn  after  the  em- 
ployment of  an  ordinary  diet  are  watery,  highly  acid,  and 
fermented  ;  on  the  addition  of  grape-sugar  they  yield  large 
quantities  of  gas  in  the  fermentation  tubes. 

The  bacteriological  signs  are  variable,  but  are  in  keep- 
ing with  the  degree  of  stagnation  and  retention  and  with 
the  quality  of  the  diet.  In  stagnation,  with  excessive  or 
active  hydrochloric  acid  secretion,  there  is  chiefly  yeast 
fermentation,  and  usually  formation  of  acetic  acid.  If  there 
be  no  free  hydrochloric  acid  after  a  test-breakfast,  the  most 
common  form  of  fermentation  is  lactic.  In  retention  the 
same  relation  obtains,  but  when  there  is  excessive  and  active 
secretion,  hydrosulphuric  acid  and  acetone  are  sometimes 
found,  and  sarcinne  are  numerous.  If  no  free  hydrochloric 
acid  is  present,  the  organic  acids  are  chiefly  lactic  and  butyric, 
sarcinae  are  rare,  and  the  fermentation  is  chiefly  bacillary. 
In  all  forms  of  retention  the  germs  actively  generate  gas  when 
the  sweetened,  unfiltered  stomach-contents  are  placed  in  fer- 


OBSTRUCTION  OF  THE   ORIFICES.  59/ 

mentation  tubes  and  kept  for  twenty-four  hours  at  the  proper 
temperature. 

Differential  Diagnosis  and  Diagnosis. — During  the  stage  of 
compensation  pyloric  obstruction  is  very  likely  to  be  over- 
looked. Digestion  is  unconscious,  except  during  the  recur- 
ring periods  of  disturbed  compensation,  when  both  patient 
and  physician  are  often  satisfied  with  the  common  explanation 
that  these  attacks  are  due  to  indigestion.  But  whenever  a 
patient  has  had  a  disease  of  the  stomach  which  is  liable  to 
be  followed  by  pyloric  obstruction,  the  recurring  attacks  of 
motor  insufficiency  should  excite  suspicion  and  lead  to  a 
careful  examination,  and  the  suspicion  should  be  increased 
whenever  a  secretory  disorder  is  absent  and  there  is  no 
trouble  in  the  intestines.  These  attacks  are  nearly  always 
produced  by  dietetic  excesses  of  a  particular  kind.  A  heavy 
meal  containing  irritants  and  easily  fermentable  articles  of 
food  may  disturb  a  normal  stomach,  but  more  readily  one  that 
is  myasthenic,  or  that  is  only  just  equal  to  the  task  of  over- 
coming a  resistance  to  its  evacuation.  But  recurring  attacks 
of  gastric  indigestion,  accompanied  by  stagnation  and  peri- 
staltic pain  or  vomiting,  with  little  or  no  fermentation,  and  not 
followed  by  diarrhea  or  intestinal  trouble,  and  caused  like- 
wise by  eating  a  large  meal  of  coarse,  solid  food,  in  the 
absence  of  fever  or  of  any  constitutional  disease,  are  most 
often  due  to  obstruction.  And  the  probability  is  greatly 
increased  if  the  patient  has  just  recovered  from  an  ulcer  or 
from  toxic  gastritis  and  if  the  stomach  feels  strong  to  the 
palpating  finger  during  its  contractions,  and  does  not  splash 
longer  than  it  normally  should  after  the  administration  of  a 
glass  of  water  while  it  is  empty.  Dietetic  excesses  invariably 
disturb  compensation,  for  the  anatomical  obstruction  is  per- 
sistent. The  detection  of  a  pyloric  tumor  at  once  removes 
all  doubt.  The  possibility  of  duodenal  obstruction  producing 
the  same  symptoms  under  the  same  circumstances  should 
not  be  forgotten. 

Gastric  stagnation  and  retention  are  either  obstructive, 
myasthenic,  or  cancerous,  and  may  be  due  to  cancerous  or 
inflammatory  infiltration  of  the  muscular  layer.  Excessive 
secretion  prolongs  digestion.  The  motor  power  of  the 
stomach  in  uncomplicated  chronic  asthenic  gastritis  is  as 
good  as  in  health.  Chronic  hypersthenic  gastritis  may  some- 
times cause  obstruction  of  the  pylorus,  and  is  frequently 
complicated,  particularly  in  its  advanced  stages,  by  motor 
insufficiency.  Cancer  may  likewise  produce  the  two  condi- 
tions in  both  ways.     When  either  stagnation  or  retention  is 


598  DISEASES  OF  7 HE  STOMACH. 

chronically    present,    the    search    for    the    causative    disease 
should  be  made  methodically. 

1.  Is  the  motor  insufficiency  due  to  obstruction  or  to  my- 
asthenia ? 

2.  Is  the  stagnation  or  retention  due  to  obstruction  or  to 
supersecretion  ? 

3.  Is  the  obstruction  pyloric  or  duodenal? 

4.  Is  the  pyloric  obstruction  benign  or  malignant  ? 

5.  What  is  the  character  of  the  benign  process  ? 

6.  What  is  the  degree  of  obstruction  ? 

I.  The  first  step  in  the  solution  of  the  problem  is  the 
search  for  a  pyloric  tumor.  The  examination  is  greatly  facili- 
tated by  the  reduction  of  abdominal  tension  through  evacua- 
tion of  the  bowels  and  bladder.  The  search  should  be  begun 
when  the  stomach  is  empty.  With  all  the  viscera  thus  empty, 
the  examination  of  the  abdomen  is  made  easier.  Any  ab- 
normality of  tlie  abdominal  organs  is  noted,  and  special 
attention  should  be  given  to  the  displacement  of  the  right 
kidney,  the  distention  of  the  gall-bladder,  and  the  search  for 
any  tumor  which  might  obstruct  the  duodenum.  The  pylorus 
should  next  be  sought,  using  the  act  of  respiration,  and  also 
the  posture  on  the  left  side,  in  order,  if  possible,  to  bring  the 
pylorus  within  reach.  The  stomach  should  next  be  moder- 
ately inflated  with  air  or  an  effervescent  powder,  and  the 
pyloric  end  of  the  stomach  and  the  position  of  the  whole 
organ  should  be  noted,  as  the  obstruction  may  be  due  to  dis- 
placement of  the  stomach.  If  a  pyloric  tumor  is  found,  the 
discovery  is  very  important.  Stagnation  or  retention,  with 
the  presence  of  a  palpable  p\'loric  tumor,  demonstrates  the 
obstructive  nature  of  the  trouble.  The  presence  of  the  other 
signs  of  obstruction,  in  contradistinction  to  myasthenia,  con- 
firm the  diagnosis. 

If  no  pyloric  tumor  can  be  felt,  a  search  for  a  displaced 
organ  or  for  a  tumor  which  might  obstruct  the  duodenum 
should  be  instituted.  In  the  absence  of  an  ulcer  history,  of 
toxic  gastritis,  of  the  signs  of  cancer,  and  of  congenital 
stenosis,  and  if  the  pylorus  can  be  felt  and  presents  no 
tumor,  duodenal  obstruction  is  the  probable  cause. 

In  the  absence  of  a  discoverable  pyloric  tumor,  and  of  any 
cause  of  duodenal  obstruction,  the  differentiation  between 
obstructive  and  myasthenic  stagnation  or  retention  must  be 
made  by  other  symptoms  which  often  have  a  distinctive  and 
conclusive  significance.  But  at  particular  moments  in  the 
evolution  of  a  number  of  cases  there  is  a  chance  to  make 
only  a  more  or  less  rational  guess. 


OBSTRUCTION  OF   THE    ORIFICES.  599 

Myasthenic  stagnation  is  a  frequent  disease  of  the  stomach. 
Myasthenic  retention  is  rare,  and  much  less  common  than  ob- 
structive retention.  In  the  one  or  the  other  degree  of  motor 
insufficiency  the  probability  is  in  favor  of  the  more  frequent 
cause. 

If  the  stagnation  or  retention  has  been  preceded  by  a  dis- 
ease likely  to  produce  obstruction,  such  is  probably  the  gene- 
sis and  nature  of  the  trouble.  In  the  absence  of  such  a  disease 
myasthenia  is  probably  the  cause,  and  the  probability  is  greater 
if  the  patient  has  gout,  or  has  recently  recovered  from  an  acute 
infectious  disease,  like  influenza  or  typhoid  fever,  and  if  the 
common  signs  of  myasthenia  are  present. 

The  evolution  of  myasthenia  is  slow  and  mild.  The  trouble 
may  exist  for  months  without  producing  any  local  symptoms, 
and  may  last  for  years  without  the  development  of  supersecre- 
tion.  Obstruction  is  usually  rapid,  painful,  and  stormy  in  its 
evolution.  During  the  stagnation  period  the  stomach  often 
becomes  intolerant;  and,  as  a  rule,  the  urine  is  much  less, 
diminished  in  quantity  than  it  is  in  myasthenia,  and  fermenta- 
tion is  much  less  active.  But  in  the  retention  period  fermenta- 
tion is  active  in  both  diseases,  and  the  difference  in  the  quan- 
tity of  urine  increases. 

In  obstruction  the  muscular  layer  of  the  stomach  often 
undergoes  hypertrophy,  and  the  peristalsis  during  digestion 
is  palpable,  sometimes  visible  and  painful.  In  myasthenia 
these  signs  of  increased  effort  and  power  are  not  found. 

In  myasthenia  vomiting  is  very  rare,  and  pain  is  nearly 
always  absent  during  the  period  of  stagnation.  In  obstruc- 
tive stagnation  both  pain  and  vomiting  are  very  common. 
During  the  retention  period  of  myasthenia  vomiting  is  infre- 
quent and  copious,  but  during  the  same  stage  of  obstruction 
vomiting,  as  a  rule,  is  more  frequent,  occurs  oftener  as  the 
climax  of  the  trouble  excited  by  a  meal,  and  is  accompanied 
sometimes  by  nausea  and  retching,  the  stomach  frequently 
retracting  after  its  evacuation.  Obstructive  retention  is  much 
more  serious  and  starves  more  rapidly  than  does  myasthenic 
retention.  Expression  of  the  contents  of  the  stomach  is  easy 
in  obstruction  ;  it  is  always  difficult  and  incomplete  in  myas- 
thenia. 

In  myasthenia  liquids  as  well  as  solid  food  stagnate  or 
are  retained.  This  peculiarity  is  so  pronounced  that  the 
disease  was  once  called  the  "  dyspepsia  of  liquids."  In  ob- 
struction, on  the  other  hand,  liquids  are  evacuated  from  the 
stomach  much  more  readily  than  semi-solid  food.  This 
fact  constitutes  the   differential  value  of  the  water-test.     In 


6oO  DISEASES  OF  TJIE  STOMACH. 

obstructive  stagnation  if  a  pint  of  water  be  given  when  the 
stoniacli  is  empty,  it  is  evacuated  within  one  and  one-half 
hours,  which  is  long  before  the  myasthenic  stomach  ceases 
to  splash  or  to  yield  water  upon  the  introduction  of  the  tube. 
Myasthenia  often  yields  readily  to  treatment,  or,  in  the 
stage  of  retention,  can  often  be  so  managed  as  to  maintain 
the  balance  of  nutrition  at  a  low  level.  Obstruction  is  much 
more  obstinate,  and  after  compensation  is  broken  it  is  sus- 
ceptible of  little  relief  except  by  operation  ;  it  is  never  cured 
by  medication,  but  its  ultimate  progress  may  be  thus 
arrested.  Other  differential  signs  are  enumerated  under 
the  retention  form  of  Myasthenia. 

2.  The  prolonged  digestion  of  hy[)erchylia  gastrica  and  of 
hypersthenic  gastritis  may  be  confounded  with  that  of  ob- 
structive stagnation.  In  one  instance  the  stagnation  is  due  to 
excessive  secretion  ;  in  the  other  the  stagnation  is  due  to  ob- 
struction. In  both  a  pint  of  water  is  evacuated  within  the 
normal  time.  But  the  contents  of  the  stomach  after  the  test- 
breakfast  are  greater  and  more  fluid,  and  have  less  of  the 
roll  in  supersecretion  than  in  obstructive  stagnation.  The 
evolution  of  digestion  is  abnormal  but  regular  in  glandular 
gastritis  and  in  hyperchylia  gastrica;  it  is  subject  to  sudden 
and  irregular  rises  and  falls  in  obstruction,  as  displayed  by 
the  irregularity  of  the  lines  which  represent  the  evolution  of 
the  total  acidity  and  of  the  free  and  combined  HCl.  In 
obstruction  secretion  ceases  when  the  stomach  no  longer 
contains  food ;  in  the  continuous  or  prolonged  secretion 
the  stomach  secretes  after  it  has  been  thoroughly  washed 
out.  In  obstruction  the  early  morning  residual  contents 
may  be  more  acid  (H  +  C)  than  the  contents  at  the  acme 
of  the  digestion  of  the  test-breakfast ;  but  this  is  never  so 
in  hypersthenic  gastritis  not  complicated  by  obstruction  or 
by  myasthenia  nor  in  hyperchylia  gastrica.  The  causation 
and  the  evolution  of  these  diseases  may  be  widely  different, 
and  the  results  of  treatment  may  be  such  as  are  obtained  in 
only  the  one  or  the  other  disease. 

3.  These  many  signs  and  symptoms  distinguish  obstruc- 
tive from  myasthenic  stagnation  or  retention,  and  from  func- 
tional or  organic  supersecretion.  Is  the  obstruction  pyloric 
or  duodenal  ? 

The  causes  of  duodenal  obstruction  are  displacement  of 
the  stomach,  malignant  neoplasms  developing  in  its  wall  or  in 
the  surrounding  parts,  compression  by  benign  tumors,  cica- 
tricial contraction  after  ulcer  or  ulceration,  local  plastic  peri- 
tonitis, impaction  of  a  gall-stone,  and,  possibly,  a  displacement 


OBSTRUCTION   OF   THE    ORIFICES.  6oi 

of  the  right  kidney.  The  obstruction  of  the  duodenum  above 
the  orifices  of  the  pancreatohepatic  duct  can  not  be  distin- 
guished from  pyloric  obstruction.  But  it  is  in  the  first  part 
of  the  duodenum  that  the  traction  of  a  displaced  stomach 
contracts  the  lumen  of  the  digestive  tube;  and  when  the 
stomach  thus  displaced  is  the  receptacle  of  stagnation  and  re- 
tention, and  its  walls  are  hypertrophied,  and  no  tumor  of  the 
pylorus  can  be  felt,  and  when  there  are  no  signs  or  history  of 
ulcer  or  cancer  of  the  stomach,  it  is  then  reasonable  to  con- 
clude that  the  obstruction  to  the  evacuation  of  the  stomach 
is  in  the  duodenum,  and  is  due  to  the  traction  and  bending. 
Obstruction  below  the  opening  of  the  common  duct  produces 
special  signs.  The  clinical  history  may  locate  the  trouble 
at  this  point,  which  may  be  more  sensitive  to  pressure  than 
are  the  other  parts  of  the  abdomen.  The  history  of  gall- 
stones or  of  duodenal  ulcer,  and  the  existence  of  a  circum- 
scribed tender  point  in  the  back  and  to  the  right  of  the  lower 
dorsal  vertebra,  are  of  particular  value  in  this  connection. 
Search  should  be  made,  also,  for  a  distended  gall-bladder  and 
for  cancer  of  this  organ.  The  vomit  and  the  contents  of  the 
stomach  furnish  signs  of  unquestionable  value.  The  vomit 
almost  continuously  contains  bile,  and,  indeed,  the  bile  is  pre- 
sent in  the  first  mouthful  brought  up,  showing  that  it  is  not 
pressed  into  the  stomach  by  the  act  of  vomiting.  No  signifi- 
cance should  be  attached  to  the  presence  of  bile  in  the  last  of 
the  matter  vomited  ;  but  this  sign  is  very  valuable,  when  re- 
peatedly obtained,  in  excluding  obstruction  of  the  pylorus  or 
of  the  first  part  of  the  duodenum.  In  duodenal  obstruction 
of  a  high  degree  the  duodenum  itself  is  the  site  of  retention. 
If  the  stomach  be  thoroughly  washed  out,  the  later  vomiting 
of  the  duodenal  contents  or  their  removal  through  the  tube 
after  massaging  the  duodenum  is  a  very  valuable  sign.  It 
should  not  be  forgotten  that  it  is  very  difficult  to  cleanse 
the  stomach  completely  when  food  is  retained ;  but  this  pro- 
cedure is  much  easier  when,  as  is  most  frequent  in  obstruc- 
tion, the  stomach  is  not  myasthenic.  Another  sign  is  the 
great  variability  of  the  free  hydrochloric  acidity  of  the  gastric 
contents,  which  is  due  to  the  variable  quantity  of  the  duodenal 
contents  regurgitated  into  the  stomach.  The  vomit  also 
contains  pancreatic  juice,  except  when  the  pancreas  is 
diseased.  The  presence  of  pancreatic  juice  in  demonstrable 
quantity  excludes  advanced  disease  of  the  pancreas,  and 
consequently  it  also  excludes  one  of  the  causes  of  duodenal 
stenosis.  The  frequent  vomiting  of  duodenal  contents  in 
association  with  gastric  retention  is  in  favor  of  obstruction  in 


602  DISEASES  OF  THE  STOMACH. 

the  lower  part  of  the  duodenum,  and  aids  in  the  exclusion 
of  obstruction  of  the  pylorus.  Duodenal  obstruction  being 
excluded,  the  benign  or  malignant  nature  of  the  pyloric 
obstruction  should  next  be  determined. 

4.  The  differentiation  of  benign  and  malignant  obstruction 
of  the  pylorus  may  be  easy  or  exceedingly  difficult,  and 
is  sometimes  impossible.  If  the  obstruction  develops  as  a 
sequel  of  ulcer  or  of  toxic  gastritis,  the  benign  and  cicatricial 
nature  of  the  obstruction  is  almost  certain,  for,  practically, 
the  cancerous  degeneration  of  ulcer  is  so  rare  that  it  may  be 
disregarded.  Where  a  knotty,  hard  tumor  can  be  felt  there  is 
most  probably  carcinoma;  and  there  is  little  room  for  doubt 
if  the  functional,  bacteriological,  blood,  and  nutritive  signs  of 
cancer  are  present.  But  too  often  the  clinical  history  and 
the  signs  are  not  so  distinctive. 

The  differentiation  is  frequently  dependent  on  a  predomi- 
nance of  probabilities,  so  that  only  a  rational  guess  at  the 
truth  can  be  made.  If  hydrochloric  secretion  is  normal  or 
excessive,  the  disease  is  probably  benign,  but  it  should  not 
be  forgotten  that  carcinoma  of  the  pancreas  and  gall-bladder 
seldom  diminishes  gastric  secretion  before  the  period  of 
cachexia  arrives.  Lactic  acid  formation  is  not  a  pathogno- 
monic sign,  as  it  may  occur  in  benign  retention  accom- 
panied by  asthenic  gastritis.  But  the  weight  of  evidence 
is  in  favor  of  cancer  where  there  is  no  free  hydrochloric  acid 
and  where  the  lactic  acid  is  formed  by  bacilli.  The  forma- 
tion of  hydrogen  sulphid  is  also  a  benign  sign.  The  con- 
tinued presence  of  sarcinae  for  a  long  period  does  not  occur 
in  carcinoma  of  the  pylorus,  this  germ  disappearing  rapidly 
when  lactic  acid  begins  to  develop.  Butyric  acid  fermenta- 
tion is  also  more  frequent  in  carcinoma.  The  functional  and 
bacteriological  signs  do  not  rapidly  change  in  benign  obstruc- 
tion, as  they  do  during  the  rapid  evolution  of  carcinoma. 
These  signs  maybe  so  grouped  as  to  produce  a  preponderant 
weight  of  evidence  in  favor  either  of  the  benign  or  the  malig- 
nant nature  of  the  obstruction.  The  functional  and  bacterio- 
logical signs  are  of  less  value  when  it  is  not  certain  that  the 
obstruction  is  pyloric  and  that  it  is  primarily  so. 

The  age  of  the  patient  is  of  very  little  value,  except  in  the 
exclusion  of  congenital  atresia  or  stenosis,  if  the  trouble 
began  after  childhood.  The  age  being  below  twenty  is 
against  cancer.  The  evolution  of  cancer  is  rapid  and  pro- 
gressive, presenting  only  short  periods  of  improvement. 
There  is  no  long  period  of  gastric  trouble  followed  by  a 
period  of  compensation  before  the  development  of  stagnation 


OBSTRUCTION  OF   THE    ORIFICES.  603 

and  retention.  Rectal  feeding  is  less  beneficial  than  in 
benign  obstruction,  and  careful  feeding  by  mouth  and  rectum 
is  powerless  against  the  progressive  loss  of  strength,  the 
excessive  albuminous  waste,  and  the  toxic  leukocytosis  of 
cancer.  The  cachexia  of  benign  obstruction  is  dry,  like  that 
of  simple  starvation,  and  with  it  is  never  found  the  fugacious 
edema  of  malignant  disease. 

The  dissemination  signs  of  cancer  should  be  carefully 
sought,  and  enlargement  of  the  abdominal  and  supraclavicular 
glands  and  secondary  nodules  in  the  liver  should  be  con- 
sidered conclusive. 

The  water-test  is  also  of  some  differential  value  in  the 
stage  of  stagnation,  water  being  evacuated  much  more 
rapidly  in  benign  than  in  malignant  disease. 

In  cases  where  only  a  few  of  these  distinctive  features  are 
found,  the  diagnosis  should  be  held  in  suspense.  Cases 
beginning  suddenly,  developing  rapidly,  with  pain  and  circum- 
scribed tender  points,  with  stagnation  or  retention,  with  the 
presence  of  free  acid,  yeast,  and  sarcinse,  without  a  palpable 
tumor  or  with  one  that  is  not  characteristic  of  either  cancer 
or  ulcer,  may  be  due  either  to  ulcer  or  to  cancer.  Under  these 
circumstances  the  most  rational  but  often  incorrect  guess  is 
obstruction  due  to  ulcer. 

A  positive  diagnosis  should  be  given  only  when  the  weight 
of  evidence  is  overwhelming;  under  other  circumstances  a 
probable  opinion  or  no  opinion  whatever  should  be  expressed, 
if  it  be  desired  to  avoid  the  unpleasant  revelations  of  an 
exploratory  laparotomy.  An  accidentally  correct  guess  pos- 
sesses no  merit,  and  a  false  opinion  would  only  yield  chagrin 
and  condemn  immodesty. 

5.  The  causes  of  benign  obstruction  are  ulcer,  ulceration, 
benign  tumors,  foreign  bodies,  arrested  development,  hyper- 
trophy, and  hyperplasia.  The  cicatricial  obstruction  of  toxic 
gastritis  is  revealed  or  excluded  by  the  clinical  history. 
Syphilitic  and  tubercular  ulceration  and  obstruction  by  benign 
tumors  and  foreign  bodies  are  not  recognizable.  Congenital 
atresia  and  stenosis  are  revealed  by  the  age  when  they  begin, 
by  their  evolution,  and  by  the  signs  and  symptoms,  already 
described,  which  they  produce.  The  hypertrophy  and  hyper- 
plasia are  characterized  by  a  preceding  productive  gastritis  in 
the  inflammatory  form,  and  by  the  presence  of  a  smooth, 
regular,  contracting  and  relaxing,  and  non-adherent  tumor, 
through  which  the  gastric  contents  spurt  and  bubble.  The 
evolution  may  be  rapid  after  the  second  degree  of  stagnation 
develops.     The  most  common  form  of  benign  obstruction  is 


604  DISEASES  OF  THE  STOMACH. 

caused  by  ulcer,  and  its  only  distinctive  signs  are  those  of  the 
ulcer  which  precedes  or  accompanies  it. 

6.  The  diagnosis  of  the  degree  of  obstruction  is  easy. 
During  the  period  of  compensation  the  stomach  empties 
itself  in  about  the  normal  time,  without  the  development  of 
an  excessive  germ  growth. 

The  period  of  stagnation  is  characterized  by  the  delayed 
evacuation  of  the  stomach.  The  test-breakfast  and  the  Leube- 
Riegel  dinner  remain  longer  than  the  normal  period  in  the 
stomach,  as  revealed  by  the  employment  of  the  tube  and 
by  splashing  sounds,  particularly  during  the  relaxation  of 
the  walls  of  the  organ.  Two  degrees  of  stagnation  may  be 
distinguished,  and  are  clinically  important.  In  the  mild 
form  the  stomach  empties  itself  after  each  of  the  three  meals. 
In  the  severe  form  the  stomach  is  found  empty  and  free  from 
splashing  only  before  breakfast. 

In  retention  the  stomach  never  completely  empties  itself, 
and  splashes  before  anything  is  taken  into  it  in  the  morning. 
Clinically,  a  particular  test  should  be  adopted  as  the  criterion. 
If  the  stomach  be  thoroughly  washed  out  in  the  evening  and 
the  Boas  supper  given,  food  should  be  found  in  it  the  fol- 
lowing morning. 

The  degree  of  retention  is  revealed  by  the  quantity  of 
urine  passed  in  the  twenty-four  hours,  provided  there  is  no 
great  loss  by  perspiration  or  by  an  intercurrent  diarrhea,  and 
provided,  further,  that  the  kidneys  are  not  diseased,  the 
stomach  not  intolerant,  and  that  three  pints  of  fluid  be  taken 
during  the  day.  Another  rough  measure  is  the  quantity  and 
composition  of  the  feces.  The  progress  of  starvation  is 
still  another  guide. 

Prognosis. — Pyloric  obstruction  is  a  very  serious  disease, 
and  the  prognosis  is  bad.  The  greater  the  obstruction,  the 
worse  is  the  outlook.  Naturally,  the  nature  and  rapidity  of 
development  of  the  causative  trouble  are  modifying  factors. 
Medical  treatment  is  palliative  ;  surgical  treatment  may  be 
curative. 

Treatment. — The  treatment  of  pyloric  obstruction  is  med- 
ical and  surgical. 

The  medical  treatment  is  only  palliative,  but  is  none  the  less 
valuable  before  an  operation  is  indicated,  and  also  when  sur- 
gical intervention  is  not  advisable  on  account  of  the  possi- 
bility of  maintaining  nutrition  by  the  administration  of  the 
proper  foods  in  the  right  manner. 

The  diet  is  the  most  important  part  of  the  treatment. 
During  the  stage  of  compensation  digestive  hygiene  and  the 


OBSTRUCTION   OF   THE    ORIFICES.  605 

avoidance  of  dietetic  excesses  and  errors  are  imperative  as 
prophylactic  measures.  The  diet  should  consist  of  the  best 
meats — like  beef,  mutton,  chicken,  white  meat  of  turkey, 
pheasant,  grouse,  quail,  squab,  and  lean  fresh  fish.  The 
cereals,  particularly  the  preparations  of  wheat  and  rice, 
thoroughly  cooked,  are  also  suitable.  Vegetables  should  be 
prepared  as  purees.  No  fat,  except  butter  or  cream  or 
Hauswaldt's  "  vigor  chocolate,"  should  be  permitted,  and  the 
sweets  should  be  of  the  simplest  sorts.  Stewed  fruits  are 
permissible  in  moderation,  and,  likewise,  the  preparations  of 
eggs  and  milk,  on  condition  that  they  are  well  borne.  The 
diet  in  this  stage  is  prophylactic,  and  in  addition  to  being 
nutritious,  digestible, and  utilizable,  should  make  the  muscular 
work  of  the  stomach  as  light  as  possible,  and  not  irritate  the 
mucous  membrane  mechanically  or  chemically  nor  favor  germ 
growth.  Fine  mechanical  subdivision,  either  by  previous 
preparation  or  by  thorough  mastication,  is  an  absolute  and 
invariable  requisite.  A  dry  diet  is  a  mistake  in  any  stage 
of  obstruction  ;  and  during  compensation  coffee,  weak  tea, 
cocoa,  and,  if  it  has  been  the  habit  of  the  patient  to  take  alco- 
holic drinks,  a  little  old  whisky  diluted,  or  old  and  light  wine, 
should  be  allowed  in  such  quantity  as  not  to  exceed  the 
limits  of  good  hygiene.  There  is  no  tendency  to  water- 
stagnation  or  retention  as  in  myasthenia,  but  coarse,  irritating, 
and  solid  food  is  liable  to  disturb  compensation.  No  incom- 
pletely fermented  nor  yeast-containing  drinks  of  any  sort 
should  be  permitted.  During  the  acute  breaks  in  compensa- 
tion the  stomach  should  be  washed  out  and  given  functional 
rest  for  twenty-four  hours,  and  the  feeding  by  mouth  should 
be  resumed  with  small  quantities  of  liquid  food.  There  is, 
during  this  stage,  no  indication  for  drugs,  and  the  stomach 
should  be  particularly  guarded  against  medication  liable  to 
derange  its  secretion.  The  general  health  should  be  main- 
tained by  hydrotherapy  and  by  good  general  and  digestive 
hygiene. 

Stagnation  is  a  sign  of  danger,  and  demands  strict  care  and 
efforts  to  restore  compensation  or  to  check  the  advance  of 
motor  insufficiency.  The  diet  for  the  stage  of  compensation 
should  be  modified  by  the  exclusion  of  all  food  which  easily 
ferments,  and  sweets,  consequently,  should  be  entirely  forbid- 
den in  many  cases.  The  food  for  the  twenty-four  hours  should 
be  divided  into  three  equal  portions,  and  so  limited  in  bulk 
as  to  obtain  the  complete  evacuation  of  the  stomach  before 
the  next   meal.     The  nourishment  should  be  fluid,  and  the 


6o6  DISEASES  OF  THE  STOMACH. 

liquids  should  be  so  increased  in  proportion  to  tlie  solids  as 
to  obtain  this  end.  Rectal  feeding  should  be  employed 
exclusively,  during  the  attacks  of  intolerance.  Strychnin, 
massage,  electricity,  and  general  neuromuscular  tonics  should 
be  used  to  restore  compensation  or  to  control  the  increasing 
insufficiency  of  the  muscular  layer.  In  the  mild  form  of 
stagnation  there  is  no  indication  for  stomach  washing,  unless 
there  be  excessive  fermentation.  But  in  the  severe  form  of 
stagnation  the  stomach  should  be  washed  out  daily  with  a 
weak  alkaline  solution  if  there  be  much  yeast  or  sarcina:. 
The  preferable  time  for  the  stomach  washing  is  in  the  early 
morning  before  breakfast,  so  as  to  remove  no  nourishment. 
But  if  the  fermentation  can  not  be  thus  controlled,  the  lavage 
should  be  performed  in  the  evening  with  Thiersch's  solution, 
and  then  with  boiled  water  to  remove  the  residuum  of  the 
solution.  Three  grains  of  resorcin  resub.  dissolved  in  a  table- 
spoonful  of  chloroform-water  should  be  left  in  the  stomach 
over  night. 

During  the  period  of  retention  the  diet  of  stagnation 
should  be  continued,  and  the  stomach  should  be  daily  washed 
out  in  the  morning  before  breakfast  with  water  alone,  or  with 
an  alkaline  solution,  or  with  Thiersch's  solution  and  water" 
A  solution  of  hydrochloric  (i  :  looo)  acid  should  be  left  in 
the  stomach  if  too  little  of  it  is  secreted  ;  or,  in  case  it  is 
secreted  in  excess,  the  stomach  should  be  left  empty,  or  a  solu- 
tion of  nitrate  of  silver  or  of  resorcin,  or  of  any  non-irritant 
anti-fermentative,  should  be  left  in  the  organ.  Rectal  feeding 
should  be  methodically  employed. 

Three  grand  principles  control  the  feeding  of  a  patient  with 
obstruction  of  the  pj^lorus. 

1.  The  stomach  must  be  empty  at  the  beginning  of  each 
meal. 

2.  All  the  food  must  be  very  finely  divided,  readily  soluble 
or  easily  rendered  fluid,  and  without  unsuitable  action  on 
secretion  or  on  the  motor  function. 

3.  The  diet  must  be  varied  and  sufficient  to  support  or  to 
improve  nutrition. 

If  the  first  principle  is  violated,  and  the  stomach  is  not 
empty  at  the  beginning  of  each  meal,  the  symptoms  will  not 
be  relieved  and  there  will  be  no  improvement.  In  the  mild 
form  of  stagnation  there  is  no  chance  to  violate  this  rule.  In 
the  severe  form  of  stagnation  it  may  be  only  necessary  to 
separate  the  meals  by  intervals  which  are  longer  than  our 
ordinary  dietetic    habits   make  them,  or  it  may  be  necessary 


OBSTRUCTION  OF   THE    ORIFICES.  607 

to  restrict  the  number  of  meals  to  two  in  the  twenty-four 
hours.  As  the  stomach  regains  its  tone  and  power  a  light 
lunch  may  be  permitted  between  breakfast  and  dinner,  but 
it  must  consist  of  food  which  rapidly  leaves  the  normal 
stomach  and  which  can  be  easily  evacuated  through  the  nar- 
row pylorus.  In  obstructive  retention  the  two-meal  system 
should  be  adopted  without  delay,  and  if  the  stomach  is  not 
empty  an  hour  before  these  two  meals,  the  stomach-tube 
must  be  used  to  render  it  so.  The  contents  should  be  re- 
moved, the  stomach  washed  out  and  left  empty. 

The  physical  properties  of  the  food  are  of  the  utmost 
importance.  The  pyloric  opening  is  small,  and  all  the  food 
must  be  such  as  can  easily  pass  through  a  small  canal. 
Naturally,  the  state  of  secretion  should  control  the  choice  of 
the  articles  of  the  diet,  and  it  may  be  necessary  to  embody 
other  dietetic  principles  in  the  management  of  particular 
cases.  But  the  minute  division  and  the  solubility  or  the  fluidity 
of  the  food  after  its  preparation  are  essential  properties,  which 
may  be  readily  secured  by  the  method  of  cooking  or  by 
straining  the  food  after  it  is  cooked.  The  crushed  and  cooked 
muscle  pulp  of  meat,  eggs  but  slightly  cooked  or  hard 
boiled  and  powdered,  fresh  fish  with  loose  and  short  fibers, 
milk  if  it  agrees  well,  cream,  butter,  cheese,  zwieback,  light 
cake,  cereal  (strained)  puddings,  light  custard,  oatmeal 
(strained),  cornmeal  mush,  corn  bread  made  of  "  round  " 
cornmeal,  rice  passed  through  a  colander,  rice  cakes,  flour 
"  ball,"  vegetables  passed  through  a  sieve,  cooked  fruit 
strained,  and  similar  articles  from  all  the  grand  classes  of 
food  may  be  ordered.  Fed  in  this  manner,  patients  with 
pyloric  obstruction  often  improve  rapidly  and  are  able  to  eat 
and  digest  a  varied  diet  comfortably. 

The  symptoms  requiring  special  medication  are  vomiting, 
pain,  and  constipation.  If  the  pain  and  vomiting  are  not 
relieved  by  the  diet  and  lavage,  and  by  functional  rest  of  the- 
stomach  obtained  by  exclusive  rectal  feeding,  codein  and 
atropin  should  be  given  hypodermically  and  a  hot  or  Winter- 
nitz  compress  should  be  placed  over  the  abdomen.  Counter- 
irritation  and  the  locally-acting  drugs  are  useless  against 
vomiting  and  pain.  Bismuth,  in  a  large  daily  dose  when  the 
stomach  is  empty,  is  an  exception  to  this  general  rule.  A 
sedative  to  both  nerve  and  muscle  should  be  used,  and  the 
codein  and  atropin  form  the  most  beneficial  combination. 
The  constipation  should  be  treated  exclusively  by  clysters  of 
water,    of   soapsuds,    of    water    and    glycerin,    or   of  water, 


6o8  DISEASES  OF   THE   STOMACH. 

glycerin,  and  oil.  The  patient  should  remain  quiet  in  bed,  so 
as  to  reduce  the  nutritive  needs  of  the  organism  and  to  con- 
serve the  ever-failing  vital  energy. 

The  only  hope  of  a  possible  cure  of  pyloric  obstruction  lies 
in  surgery.  Numerous  operations  have  been  advocated  and 
performed.  Loreta's  digital  divulsion  is  not  a  good  operation, 
since  it  is  often  inefficient,  only  practicable  in  a  few  cases,  and 
about  as  dangerous  as  the  operations  which  give  greater  hope 
of  benefit.  Gastrostomy  and  a  permanent  pyloric  tube, 
through  which  the  patient  is  fed,  can  not  be  said  to  decrease 
very  much  the  discomfort  of  the  patient.  Bernay's  curetting 
operation  has  justly  found  but  little  favor.  Duodenostomy 
has  proved  objectionable.  Jejunostonn-  has  only  one  indica- 
tion— cancerous  degeneration  of  the  body  of  the  stomach, 
rendering  gastro-enterostomy  impracticable.  There  remain 
pylorectomy,  pyloroplast}-,  gastro-enterostomy,  and  combined 
pylorectomy  and  gastro-enterostomy. 

The  choice  of  an  operation  is  determined  by  the  nature  of 
the  obstruction,  the  existence  of  adhesions,  the  degree  of 
atrophy  of  the  muscular  layer,  and  the  strength  of  the  patient. 
For  localized  and  unadherent  carcinoma,  pylorectomy  and 
combined  pylorectomy  and  gastro-enterostomy  are  the  opera- 
tions to  be  chosen.  If  the  carcinoma  is  already  disseminated 
or  adherent,  gastro-enterostomy  is  the  proper  palliative  opera- 
tion. The  ideal  operation  for  cicatricial  stenosis  is  pyloro- 
plasty. In  case  it  is  not  practicable  on  account  of  adhesions  or 
induration  and  thickening,  gastro-enterostomy  should  be  per- 
formed. 

Indications  for  an  operation  are  present  much  earlier  than 
are  usually  admitted  by  the  physician  or  accepted  by  the 
patient,  who,  as  a  rule,  gives  his  consent  only  when  death 
stares  him  in  the  face.  An  operation  should  be  advised  in  can- 
cerous obstruction  as  soon  as  the  nature  of  the  obstruction  is 
recognized,  and  the  earlier  it  is  done,  the  better  are  the  chances 
of  prolonging  life  and  making  the  patient  more  comfortable. 
Continuous  obstructive  retention,  however  caused,  demands 
surgical  intervention  as  soon  as  the  stomach  can  be  prepared 
for  operation,  especially  if  a  judicious  effort  has  failed  to  restore 
compensation  to  such  a  degree  as  to  render  it  possible  to  nour- 
ish the  patient.  The  same  rule  holds  good  in  the  severe  form  of 
obstructi\'e  stagnation  accompanied  by  much  suffering,  or  by 
the  first  stages  of  starvation,  or  by  rapid  progress  of  the  dis- 
ease. Operation  should  be  deferred  in  the  mild  form  of  benign 
obstructive  stagnation. 


OBSTRUCTION  OF  THE   ORIFICES.  609 

The  reestablishment  of  the  permeabiHty  of  the  digestive 
tube  relieves  all  the  symptoms  due  to  the  stagnation  and 
retention — the  appetite  improves,  the  patient  gains  weight  and 
strength,  the  vomiting  and  pain  cease.  But  in  carcinoma  the 
secretory  function  is  not  restored,  a  result  due  in  all  prob- 
ability to  glandular  degeneration  or  transformation.  The 
motor  function  is  restored  and  the  enlarged  stomach  retracts, 
unless  the  disease  is  so  far  advanced  as  to  produce  atrophy 
or  degeneration  and  infiltration  of  the  muscular  coat. 


39 


SECTION  VI. 
THE  ViaOUS  CIRCLES  OF  THE  STOMACH. 

CHAPTER  I. 

OTHER  ORGANS  IN  THE  DISEASES  OF  THE  STOMACH,  OR 
THE  STOMACH  IN  THE  CAUSATION  OF  DISEASE. 

There  is  no  doubt  that  the  diseases  of  the  stomach  some- 
times play  an  important  part  in  the  causation  of  disease,  but 
we  consider  it  true,  also,  that  the  effects  of  a  diseased  stomach 
are  often  overestimated.  Probably  no  other  organ  more 
frequently  becomes  diseased  secondarily,  but  the  vicious 
circles  established  between  the  stomach  and  the  other  impor- 
tant organs  of  the  body  seldom,  in  comparison,  begin  in  the 
stomach.  We  strongly  oppose  the  theory  which  makes  the 
diseased  stomach  an  all-important  disease  factory. 

Many  of  the  effects  of  diseases  of  the  stomach  are  merely 
passing  and  variable  symptoms  ;  but  other  effects  are  more 
persistent  and  constant.  It  is  these  constant  and  persistent 
effects  which  we  wish  to  describe,  constituting  complications 
or  sequelae  linked  in  close  causal  relation  with  the  disease  of 
the  stomach. 

The  stomach  as  a  disease-producing  organ  may  act  in  sev- 
eral ways — through  its  influence  on  intestinal  digestion  and  on 
nutrition,  through  its  disturbance  of  physiological  chemistr\-, 
and  through  auto-intoxication.  The  influence  on  intestinal 
digestion  is  direct,  the  abnormal  chyme  producing  abnormal 
chylification.  On  all  other  organs  the  diseased  stomach  acts 
either  through  the  nervous  system  or  through  the  blood. 
It  is  difficult  to  determine  how  much  disturbance  is  due  to 
refle.x  action  ;  it  is  difficult  to  know  how  far  the  peripheral 
irritation  involves  the  sympathetic  and  cerebrospinal  centers  ; 
it  is  difficult  to  discover  how  far  the  chemistry  of  the  body 
is  altered  in  a  particular  case  by  the  diseased  stomach  ;  and 
it  is  far  more  difficult  to  estimate  with  precision  the  injury 
done  by  auto-intoxication. 

The  existence  of  gastric  auto-intoxication  is  only  an  infer- 

6io 


THE   VICIOUS  CIRCLES  OF  THE   STOMACH.  6ll 

ence,  and  the  correctness  of  the  inference  is  denied  by  some 
writers.  It  is  claimed  that  the  total  quantity  of  the  fermen- 
tation acids  formed  in  the  stomach  is  not  great ;  that  few  of 
them  are  toxic,  even  in  large  quantity;  that  they  are  combined 
and  diluted  by  the  blood,  that  some  of  them  are  so  harmless 
as  to  serve  as  food ;  and  that  putrefaction,  which  is  the  chief 
source  of  poisons,  occurs  in  the  stomach  seldom  and  irregu- 
larly and,  indeed,  almost  accidentally.  Clinical  and  experi- 
mental evidence  is  not  conclusive,  it  is  true,  as  to  the  existence 
of  gastric  auto-intoxication,  but  it  would  seem  that  iconoclasm 
threatens  to  go  too  far.  The  toxicity  of  the  gastric  juice  is 
much  greater  in  some  of  the  diseases  of  the  stomach  than  in 
health ;  the  toxicity  of  the  urine  is  often  increased  in  the 
diseases  of  the  stomach  accompanied  by  toxemic  symptoms, 
although  the  bowels  be  healthy  and  the  liver  show  no  signs 
of  functional  insufficiency ;  there  are  often  present  in  the 
diseased  stomach,  and,  indeed,  in  a  state  of  active  and  virulent 
growth,  germs  which  produce  poisons  in  cultures.  These  are 
conclusions  deduced  from  our  investigations.  Hydrogen 
sulphid  formed  in  the  stomach  and  found  in  the  breath  and 
in  the  urine  gives  rise  to  a  special  symptom-group  on  its  way 
through  the  system.  Butyric  acid  certainly  produces  local 
irritation  and  systemic  symptoms.  Acetone  is  sometimes 
found  in  the  stomach  when  oxybutyric  acid  and  acetone  are 
found  in  the  urine.  Moreover,  the  toxicity  of  the  urine  is  no 
index  of  the  toxemia,  for  gastric  poisons  are  not  eliminated 
by  the  kidneys  only,  and  it  is  probable  that  some  of  them,  at 
least,  are  changed  into  simpler  and  non-poisonous  compounds 
during  their  passage  through  the  body.  Furthermore,  the 
absence  of  a  perceptible  increase  of  the  toxicity  of  either  the 
gastric  contents  or  the  urine  does  not  exclude  the  existence 
of  slow,  chronic  self-poisoning.  The  denial  of  the  existence 
of  gastric  self-poisoning  is  based  on  a  simple  negation,  and 
can  not  be  justly  made  in  disregard  of  the  clinical  and 
experimental  evidence  which  we  have,  however  little  it 
may  be. 

I.  INFLUENCE  ON  THE  INTESTINES. 

The  functions  of  the  intestines  may  be  disordered  indi- 
rectly by  the  injurious  influence  of  the  diseases  of  the  stomach 
on  the  nervous  system,  on  the  liver,  on  the  blood,  on  nutri- 
tion, on  the  circulation,  and  on  the  kidneys ;  but  there  can  be 
no  question  that  their  most  direct  action  is  on  the  intestines 
by  reflexes  originating  in  the  stomach  and  conveyed  by  the 


6l2  DISEASES  OF  THE  STOMACH. 

sympathetic  and  the  pneumogastric  nerves.  These  influences, 
however,  are  difficult  to  define,  and  they  may  be  dismissed 
with  this  brief  notice  in  order  that  we  may  pass  at  once  to 
the  consideration  of  the  more  important  disturbances  which 
occur  in  virtue  of  the  close  association  of  the  stomach  and 
intestines  in  digestion,  and  of  their  being  but  divisions  of  the 
digestive  tube  with  one  grand  work  in  common. 

Whenever  the  stomach  fails  to  do  its  required  digestive 
work  an  additional  burden  is  thrown  on  the  intestines.  If 
the  nitrogenous  food  is  not  properly  peptonized,  and  if  the 
bundles  of  muscular  fibers  are  not  unbound,  as  is  the  case  in 
insufficiency  of  the  secretory  and  motor  functions,  the  omitted 
work  must  be  performed  in  the  bowels.  If  the  action  of  the 
saliva  is  too  rapidly  arrested  in  the  stomach,  the  intestines 
must  convert  more  than  their  share  of  the  carbohydrates. 
The  healthy  intestines,  as  is  well  known,  are  capable  of  per- 
forming this  e.xtra  work  perfectly,  and  the  digestion  and  the 
utilization  of  the  food  may  be  as  good  as  when  both  the 
stomach  and  intestines  do  their  work  normally.  But  the 
extra  work  is  a  menace  to  the  integrity  of  the  functions  of 
the  intestines,  and  their  susceptibility  to  disease  is  increased. 

A  disease  which  disorders  the  digestive  work  of  the 
stomach,  disorders,  as  a  necessary  consequence,  the  secretion 
and  peristalsis  of  the  intestines.  It  is  well  known  that  the 
saliva  and  the  products  of  salivarj'  digestion  are  physiological 
excitants  of  gastric  secretion.  If  the  saliva  be  excluded  from 
the  food  and  its  entrance  into  the  stomach  prevented,  the 
activity  of  the  secretion  of  hydrochloric  acid  and  the  two 
gastric  ferments  during  the  digestion  of  the  test-breakfast  is 
reduced  to  about  one-half  of  what  it  should  be.  The  products 
of  gastric  digestion,  also,  excite  the  functions  of  the  stomach. 
Chyme,  on  the  other  hand,  as  it  undergoes  conversion  into 
chyle,  is  the  physiological  excitant  of  intestinal  secretion  and 
peristalsis,  so  that  an  alteration  of  the  composition  of  the 
chyme  must  entail  an  alteration  of  intestinal  secretion  and 
peristalsis.  This  alteration  may  be  compensatory  or  it  may 
be  so  great  as  to  produce  functional  insufficiency. 

Now.  functional  insufficiency  of  the  intestines,  whether  it 
be  produced  by  extra  work  or  by  disordered  gastric  secretion 
and  peristalsis,  favors  intestinal  fermentation  and  putrefaction, 
and  these  in  turn  become  active  enemies  of  intestinal  health. 
Thus  the  diseases  of  the  stomach  which  are  accompanied 
by  disorders  of  secretion  (excessive  or  diminished)  and 
by  disorders  of  the  motor  function  (excessive  or  diminished) 
produce  naturally  disorders   and   diseases   of  the   intestines. 


THE    VICIOUS  CIRCLES  pE  THE   STOMACH  613 

If  the  disease  of  the  stomach  be  accompanied  by  excessive 
gastric  secretion,  the  carbohydrates  must  be  digested  by  the 
bowels,  and  the  gastric  digestion  of  albumin  is  very  active. 
If  sweets  are  not  excluded  from  the  diet,  gastric  fermentation 
may  become  active,  and,  continuing  in  the  intestines,  it  may 
prevent  intestinal  putrefaction ;  but  even  in  this  condition 
putrefaction  is  likely  to  begin  in  the  cecum,  where  the  con- 
tents first  become  nearly  neutral  or  alkaline.  The  colonic 
putrefaction  is  not  accompanied  by  indicanuria,  but  it  is 
manifested  by  very  foul  stools,  and  by  the  excessive  formation 
of  H2S  gas.  If  sweets  be  excluded  from  the  diet,  gastric 
fermentation  may  be  controlled,  but  intestinal  putrefaction 
then  begins  high  up  in  the  small  bowel,  and  the  contents 
become  thoroughly  rotten  in  the  colon.  Indicanuria  is  very 
marked,  and  putrefaction  and  pancreatic  superdigestion  are 
only  favored  by  the  excessive  gastric  peptonization  in  the  same 
manner  as  when  predigested  foods  are  eaten.  If  the  disease 
of  the  stomach  be  accompanied  by  diminished  gastric  secre- 
tion, salivary  digestion  is  very  active  and  the  digestion  of  the 
albumins  is  thrown  on  the  bowels.  Fermentation  begins 
high  up  in  the  small  intestines  (even  in  the  stomach,  if  there 
be  motor  insufficiency),  and  continues  as  long  as  the  intesti- 
nal contents  contain  fermentable  matter.  Putrefaction  does 
not  occur  in  the  small  bowel,  and  the  fermentation  is  usually 
active  enough  to  prevent  excessive  putrefaction  in  the  colon. 
If  gastric  stagnation  or  retention  be  present,  there  will  be  in- 
testinal putrefaction  or  fermentation  according  to  the  reaction 
of  the  chyle  and  its  richness  in  peptones  or  carbohydrates. 
Consequently,  in  diseases  of  the  stomach  which  are  accompan- 
ied by  disorders  of  secretion  and  by  disorders  of  the  motor 
function,  intestinal  secretion  and  peristalsis  may  be  disturbed, 
the  food  may  be  lost  by  fermentation  and  putrefaction  (the 
analysis  of  the  stools  showing  only  an  apparently  normal 
utilization),  auto-intoxication  may  be  produced,  and  enteritis, 
colitis,  or  enterocolitis  may  result.  Diminished  gastric  secre- 
tion also  favors  enteric  infection. 

Finally,  gastroptosis  may  be  primary  and  cause  enterop- 
tosis,  and  this  process  is  but  little  less  frequent  than  the  pro- 
duction of  gastroptosis  by  the  primary  prolapse  of  the  colon. 
Gastro-enteroptosis  may  induce  chronic  changes  in  the  abdo- 
minal sympathetic  and  in  the  nutrition  of  the  intestines. 
Enteritis  membranacea  may  then  be  an  ultimate  effect. 


6l4  DISEASES  OF   THE   STOMACH. 


11.  INFLUENCE  ON  THE  LIVER. 

Tlie  manifold  functions  of  the  liver — the  largest  and  most 
important  gland  of  the  body — may  be  disordered  by  diseases 
of  the  stomach. 

The  liver  is  an  organ  of  assimilation  and  disassimilation. 
This  nutritive  function  may  be  disordered  by  the  products 
of  abnormal  digestion  and  by  auto-intoxication,  or  it  may  be 
disturbed  on  account  of  the  irritation,  or  the  overwork;  or 
the   required  performance  of  unusual  work. 

The  liver  is  also  a  poison-destroying  organ.  It  accumu- 
lates, eliminates,  and  destroys  the  poisons  which  are  carried 
to  it  by  the  portal  vein.  This  function  can  be  disturbed  by 
auto-into.xication  and  by  the  absorption  (without  conversion) 
of  the  products  of  peptonization.  Peptones  and  digestive 
albumoses,  when  they  get  into  the  circulation  without  being 
first  transformed,  act  as  poisons. 

The  liver  is  also  a  digestive  organ,  for  the  bile  exerts  a 
marked  influence  on  the  intestinal  digestion  and  utilization  of 
food.  The  quantity  and  activity  of  its  secretion  is  dependent 
in  part  on  the  quantity  and  quality  of  the  food  and  on  the 
composition  of  the  chyme,  a  large  mixed  meal  when  it  is 
normally  digested  by  the  stomach  being  the  most  active 
cholagogue  known.  This  physiological  and  purposive  secre- 
tion of  bile  may  be  disordered  by  the  diseases  of  the  stomach 
which  require  a  modification  of  the  diet  as  regards  the  pro- 
portion of  the  grand  classes  of  food  which  enter  into  its 
composition,  which  withhold,  by  retention  or  by  vomiting, 
the  required  quantity  of  food,  and  which  alter  by  secretion, 
digestive  transformation,  fermentation,  and  putrefaction  the 
normal  properties  of  the  chyme. 

The  liver  is  a  blood-destroying  organ,  and  it  has  probably 
something  to  do  with  blood  building  and  with  the  mainten- 
ance of  the  composition  of  the  plasma.  This  function  may 
be  disordered  indirectly  by  the  diseases  of  the  stomach 
through  their  action  on  the  blood  (hematocytolysis)  and 
through  the  association  of  disordered  functions.  If  one 
function  of  the  liver  becomes  disordered,  the  other  functions 
may  be  compromised  with  it. 

Consequently,  the  functions  of  the  liver  may  be  disordered 
by  disease  of  the  stomach.  Hepatic  insufficiency  may  be 
thus  established,  or  the  organ  may  become  congested  and, 
finally,  inflamed.  The  congestion  and  inflammation  may  be 
acute  or  chronic.     It  is  likely  that  the  functions   of  the  liver 


THE    VICIOUS  CIRCLES  OF  THE    STOMACH.  615 

may  be  deranged  by  reflexes  from  the  diseased  stomach,  in 
the  same  manner  that  gall-stones  produce  hyperchlorhydria 
and  hyperchylia  gastrica,  or  that  they  may  be  deranged  by 
the  action  of  the  diseased  stomach  on  the  cardiovascular 
system.  Carcinoma  and  ulcer  of  the  stomach  may  produce 
hepatic  complications. 


III.  INFLUENCE  ON  THE  BLOOD. 

The  injurious,  influence  of  diseases  of  the  stomach  on  the 
blood  is  exerted  in  several  different  ways  : 

1.  Diseases  of  the  stomach  frequently  produce  inanition- 
anemia,  which  is  the  sequel  of  subnutrition.  Inanition 
acts  in  two  principal  ways  on  the  blood.  It  may  produce 
insufficiency  of  the  hematopoietic  organs,  just  as  it  pro- 
duces general  functional  inactivity  ;  or  it  may  alter  the  com- 
position of  the  plasma  so  that  it  becomes  poor  in  nitrogenous 
matter,  the  resistance  of  the  red  corpuscles  being  diminished 
and  the  development  of  the  white  corpuscles  being  decreased. 
Consequently,  subnutrition  may  produce  dyshematopoietic 
oligocythemia,  or  the  dyshematopoiesis  may  be  accompanied 
by  hematocytolysis,  as  is  the  case  in  the  grave  anemia  of 
atrophy  of  the  gastric  glands. 

2.  The  diminished  supply  and  the  diminished  absorption 
of  water,  and  its  increased  elimination  by  supersecretion 
or  vomiting,  may  produce  oligemia  sicca.  The  oligemia 
may  be  simple,  the  red  corpuscles  being  normal  in  number, 
in  coloring  (hemoglobin),  in  size,  in  form,  in  resistance,  and  in 
their  affinities  for  stains ;  or  the  oligemia  sicca  may  mask  a 
disease  of  the  red  corpuscles,  the  deception  being  quickly 
made  plain  by  the  use  of  the  microscope. 

3.  The  loss  of  blood  by  hemorrhage  (ulcer,  carcinoma, 
erosions)  produces  an  acute  or  chronic  anemia,  which  may  be 
mild,  severe,  or  grave.  Oft-repeated  small  hemorrhages  pro- 
duce a  grave  and  rebellious  form  of  anemia  when  the  daily 
or  frequent  losses  of  blood  exceed  the  quantity  of  blood 
supplied  by  the  hematopoietic  organs. 

4.  Auto-intoxication  does  more  direct  and  more  extensive 
injury  to  the  blood  than  it  does  to  the  nervous  system,  the 
cytoplasmic  poisons  destroying  the  red  corpuscles  and  the 
activity  of  the  blood-building  organs  are  decreased.  Con- 
sequently, the  anemias  of  auto-intoxication  may  be  dyshema- 
topoietic or  hematocytolytic. 

5.  The  blood  may  also  be  injuriously  affected  by  the  influ- 


6l6  DISEASES  OF  THE  STOMACH. 

ence  of  gastric  secretion  or  retention  on  the  percentage  of 
salines  in  the  blood.  The  sodium  chlorid  is  most  reduced 
in  this  manner,  and  the  plasma  may  thus  become  hema- 
tocytolytic. 

6.  Clinical  observation  teaches  that  chronic  irritation  of 
the  abdominal  sympathetic  exerts  a  depressing  influence  on 
the  regeneration  of  the  blood,  particularly  as  regards  the 
development  of  the  hemoglobin  of  the  red  corpuscles.  The 
action  of  the  irritable  abdominal  s}-mpathetic  (gastroptosis, 
adenohypersthenia  gastrica,  neurasthenia  gastrica)  is  the  most 
common  cause  of  simple  and  of  chlorotic  oligochromemia. 

7.  Peptonization  and  peptone  absorption  are  causes  of 
physiological  leukocytosis,  and  in  the  advanced  stages  of  some 
of  the  diseases  of  the  stomach  this  digestive  leukocytosis  is  not 
excited.  As  a  consequence  the  resisting  power  (healing  and 
phagocytosis)  of  the  system  is  diminished,  and  the  normal 
quantity  of  albumins  in  the  plasma  is  not  maintained.  Leu- 
kopenia may  be  produced  by  subnutrition  or  by  the  absorp- 
tion of  the  unconverted  products  of  albumin  digestion. 

8.  Pathological  leukocytosis  may  develop  in  carcinoma 
and  in  the  diseases  of  the  stomach  with  inflammatory  com- 
plications. 

As  regards  the  diseases  of  the  red  corpuscles,  diseases  of 
the  stomach  may  produce  either  oligochromemia  or  oligocy- 
themia. Oligochromemia  is  always  dyshematopoietic,  unless 
it  represents  the  regeneration  period  of  oligocythemia.  The 
disease  and  the  symptom  may  be  readily  distinguished  by 
the  clinical  history  and  by  the  microscopic  and  staining 
properties  of  the  blood.  Oligocythemia,  on  the  other  hand, 
may  be  dyshematopoietic,  hematocytolytic,  or  degenerative. 
The  diseases  of  the  stomach  never  cause  the  red  corpuscles 
to  undergo  primary  degeneration.  Consequently,  oligocy- 
themia of  gastric  origin  is  always  due  either  to  insufficient 
and  defective  development  of  the  blood  or  to  the  excessive 
destruction  (or  loss  by  hemorrhage)  of  the  red  corpuscles. 
These  two  forms  of  oligocythemia  may  be  readily  distin- 
guished by  the  signs  of  dyshematopoiesis  and  by  the  signs 
of  hematocytolysis,  a  discussion  of  which  here  would  lead 
too  far  from  the  original  subject. 

Of  the  diseases  of  the  white  corpuscles,  leukemia  is  never 
produced  by  the  diseases  of  the  stomach.  But  digestive  leu- 
kocytosis may  not  occur,  pathological  leukocytosis  may  be 
persistently  present,  the  white  corpuscles  may  degenerate  (as 
many  as  ten  per  cent,  of  them  may  display  the  degenerative 
changes),  or  leukopenia  may  represent  the  chief  alteration  of 


THE   VICIOUS  CIRCLES  OF  THE   STOMACH.  617 

the  blood.  The  plasma  may  be  altered  qualitatively  or  quanti- 
tatively and  become  as  a  consequence  hematocytolytic,  or  the 
total  volume  of  the  blood  may  be  decreased. 

The  changes  of  the  blood  which  are  produced  by  the  dis- 
eases of  the  stomach  are  not  so  constant  or  so  characteristic 
as  to  enable  us  to  reason  back  from  the  disease  of  the  blood, 
to  the  particular  disease  of  the  stomach  which  has  caused  it ; 
but  a  particular  disease  of  the  blood  should  direct  the  search 
for  the  group  of  diseases  of  the  stomach  which  may  cause 
it,  and  the  blood  changes  have  some  diagnostic  value  in  the 
differentiation  of  one  disease  or  group  of  diseases  of  the 
stomach  from  another.  The  blood  changes  produced  by  the 
particular  diseases  of  the  stomach  have  been  described  under 
the  symptomatology  of  those  diseases. 


IV.  INFLUENCE  ON  NUTRITION. 

Not  every  disease  of  the  stomach  disturbs  nutrition.  In 
some  cases  the  digestion  and  utilization  of  the  food  may  be 
normal;  assimilation  and  disassimilation  may  go  on  as  in 
health ;  enough  food  may  be  ingested  and  retained  to  supply 
the  needs  of  nutrition.  But  such  is  not  always  the  case,  not 
even  in  the  dynamic  affections  of  the  stomach  nor  in  the  mild 
forms  of  its  anatomical  diseases.  The  acute  diseases  of 
the  stomach  may  rapidly  affect  nutrition,  and  the  chronic 
diseases  seldom  run  their  long  course  without  producing 
subnutrition  or  without  disturbing  the  processes  of  nutrition. 
The  most  frequent  of  these  disorders  of  the  processes  of 
nutrition  are  excessive  nitrogenous  waste,  uricemia,  and  phos- 
phaturia. 

Subnutrition  may  be  caused  by  a  disease  of  the  stomach 
in  a  number  of  ways,  and  it  may  vary  in  degree  and  in  the 
rapidity  of  its  development.  The  diet  is  often  insufficient  on 
account  of  loss  of  appetite,  on  account  of  disgust  for  some 
one  of  the  grand  classes  of  food,  on  account  of  a  desire  to 
avoid  the  pain  or  discomfort  of  digestion,  or  on  account  of 
an  injurious  plan  of  alimentation.  Moreover,  when  the 
alimentation  is  sufficient,  a  portion  of  the  food  may  be  lost  by 
vomiting,  by  fermentation,  by  putrefaction,  by  diarrhea,  or 
by  failure  to  digest  and  absorb  it  to  the  same  degree  as  in 
health.  In  the  advanced  cases  of  anorexia  nervosa  the 
patient  presents  a  picture  of  slow  and  self-inflicted  star- 
vation, and  the  loss  of  appetite  in  the  anatomical  diseases 
like  carcinoma,  chronic  asthenic  gastritis,  and  acute  gastritis 


6l8  DISEASES  Of  THE  STOMACH. 

is  one  of  tlie  causes  of  subnutrition.  The  pain  of  ulcer, 
of  chronic  hypersthenic  gastritis,  of  adenohypersthenia 
gastrica,  or  of  carcinoma,  the  discomfort  of  neurasthenia 
gastrica,  and  of  hyperesthesia  gastrica,  and  of  the  diseases 
accompanied  by  retention  and  by  stagnation,  often  force 
the  patient  to  diminish  the  quantity  and  to  contract  the 
variety  of  the  food  below  the  requirements  of  the  body. 
Moreover,  chronic  pain  itself  exerts  a  depressing  influence 
on  digestion  and  is  a  cause  of  emaciation.  Frequently 
repeated  alimentary  vomiting,  whether  it  be  nervous,  cen- 
tral, or  refle.x,  or  symptomatic  of  a  disease  of  the  stomach, 
may  produce  subnutrition  as  surely  as  does  the  failure  to  eat 
enough  to  support  the  body.  In  myasthenia  gastrica  and  in 
pyloric  obstruction — briefly,  whenever  motor  insufficiency 
exists — nutrition  is  in  more  or  less  danger;  if  there  be  only 
stagnation,  the  influence  on  nutrition  is  determined  by  the 
degree  of  fermentation  of  the  chyme;  while  if  there  be  reten- 
tion, the  body  may  starve  for  lack  of  both  food  and  water. 
It  is  well  known  that  the  intestines  are  capable  of  doing  all 
the  digestion  and  absorption  that  the  body  requires,  but  motor 
insufficiency  may  withhold  the  opportunity  to  establish  diges- 
tive compensation.  The  disturbances  of  secretion  may  also 
produce  subnutrition.  If  secretion  be  excessive, — as  in  adeno- 
hypersthenia gastrica,  in  chronic  hypersthenic  gastritis,  and  in 
ulcer, — the  digestion  of  the  starches  is  interfered  with  in  the 
stomach,  and  the  excessive  peptonization  of  the  albumins 
may  increase  intestinal  putrefaction  and  produce  intestinal 
irritation  and  diarrhea.  Nature  here  does  what  the  physi- 
cian often  causes  when  he  prescribes  the  digestive  ferments 
and  peptonized  foods.  If  secretion  be  diminished,  the  albu- 
mins may  not  be  properly  digested,  but  the  salivary  diges- 
tion of  the  starches  is  more  active  than  in  health,  and  the 
intestines,  if  they  be  healthy,  are  likely  to  establish  diges- 
tive compensation.  But  it  often  happens  that  loss  of  appe- 
tite, pain,  faulty  alimentation,  vomiting,  disorders  of  secre- 
tion, motor  insufficiency,  fermentation,  and  an  abnormal 
chyme  act  more  or  less  in  concert,  and  produce  subnutrition 
which  is  more  or  less  rapid  and  grave. 

Excessive  nitrogenous  waste  may  be  caused  by  a  disease 
of  the  stomach.  In  subnutrition  not  only  the  body  fat  but 
also  the  body  protoplasm  is  destroyed.  The  organism  eats 
itself — lives  on  itself.  But  in  carcinoma,  in  some  cases  of 
acute  mycotic  gastritis,  and,  probably,  in  some  forms  of  gas- 
tric auto-intoxication,  nitrogenous  catabolism  is  in  excess  of 
the  requirements  of  the  body.     The  hyperazoturia   manifests 


THE    VICIOUS   CIRCLES    OE   THE    STOMACH.  619 

a  purposeless  waste  of  albumin.  The  inference  seems  plausi- 
ble that  the  excessive  destruction  of  cellular  protoplasm  is  due 
to  protoplasmic  poisons  formed  in  the  neoplasm  or  in  the  con- 
tents of  the  stomach. 

The  diseased  stomach  may  cause  accumulation  of  uric  acid 
in  the  system  by  producing  acid  auto-intoxication.  The  so- 
called  uric  acid  diathesis  is  not  a  morbid  entity  with  one 
cause,  but  it  is  a  chemical  condition  which  is  variable  in  its 
manifestations  and  complex  in  its  causation.  The  accumu- 
lation or  precipitation  of  uric  acid  in  the  organism  is  the 
result  of  pathological  chemistry,  and  is  the  expression  of  a 
series  of  diseases  which  are  commonly  classified  as  gouty. 
There  is  no  insufficient  oxidation,  for  uric  acid  is  the  end 
product  of  nuclein  waste.  There  may  or  may  not  be  an 
excessive  formation  of  uric  acid.  There  may  or  may  not 
be  retention  of  uric  acid  as  a  result  of  the  insufficiency  of 
the  eliminating  organs.  There  may  be  no  quantitative 
anomaly,  but  only  a  change  in  the  form  in  which  the  uric 
acid  exists,  as  a  result  of  the  altered  reaction  and  composi- 
tion of  the  fluids  of  the  body.  It  is  probable  that  uric  acid 
circulates  in  the  body  as  a  quadriurate,  or  as  a  biurate  in 
combination  with  the  neutral  phosphate  of  soda.  Be  this 
as  it  may,  the  precipitation  of  the  uric  acid  is  prevented  by 
the  accompaniment  of  a  sufficient  proportion  of  the  neutral 
disodic  phosphate.  If  the  biurate  or  quadriurate  increases 
proportionately  beyond  a  certain  limit,  or  if  the  neutral  phos- 
phate of  soda  decreases  beyond  a  certain  limit,  there  will  be 
precipitation.  Consequently,  the  precipitation  of  the  urates  is 
inaugurated  either  by  a  diminution  of  the  available  neutral 
phosphate  or  by  an  increase  of  the  uric  acid.  Furthermore, 
the  available  neutral  phosphate  may  be  decreased  by  a 
diminished  supply  of  protecting  alkalies  or  by.  an  increased 
supply  of  converting  acids.  We  therefore  recognize  three 
grand  forms  of  the  uric  acid  diathesis  or  uric  acid  precipitation  : 

1.  Gastro-intestinal  form. 
{a)  Acid  fermentation. 

(^)  Excessive  pancreatic  and  intestinal  secretion. 
{c)  Diminished  gastric  secretion. 

2.  Nutrition  form  (excessive  formation  of  acids  :  phos- 

phoric and  organic,  or  uric  acid). 
{a)  Defective  alimentation. 
[b]  Excessive  catabolism. 

3.  Retention  form  (defective  elimination  of  acids). 
{a)  Insufficiency  of  the  skin. 

{b)  Insufficiency  of  the  kidneys. 


620  DISEASES  OF  THE  STOMACH. 

The  gastro-intestinal  form  of  the  uric  acid  trouble  is  due  to 
the  excessive  acidity  of  the  system  and  to  the  resulting  dim- 
inution of  the  quantity  of  the  neutral  phosphate  of  soda 
which  is  available  for  holding  the  uric  acid  compounds 
in  solution.  The  stomach  removes  the  chlorin  to  form 
hydrochloric  acid,  and  leaves  the  alkaline  base  of  the  chlorid 
for  the  protection  of  the  neutral  phosphate.  The  excessive 
secretion  of  the  intestines  and  of  the  accessory  digestive 
glands  removes  too  much  of  the  protecting  alkalies.  Fermen- 
tation produces  acid  self-poisoning.  The  result  is  excessive 
acidity  or  diminished  alkalinity  of  the  fluids  of  the  body, 
diminution  of  the  available  neutral  phosphate  of  soda,  and 
precipitation  of  the  uric  acid  compounds.  Ninety  grains  of 
bicarbonate  of  soda  administered  before  breakfast  is  sufficient, 
in  health,  to  neutralize  the  acidity  of  the  system  and  to  ren- 
der the  urine  secreted  during  the  following  two  hours  neutral 
in  reaction.  If  the  urine,  on  making  this  test,  does  not  be- 
come neutral,  its  acidity  is  the  exact  index  of  the  excessive 
acidity  of  the  system.  The  gastric  form  of  gout  results  only 
from  a  chronic  disease  of  the  stomach,  and  is  most  frequent 
when  the  diminished  gastric  secretion  and  gastric  fermenta- 
tion are  accompanied  by  excessive  intestinal  secretion. 
Chronic  asthenic  gastritis  with  motor  insufficiency,  carcinoma, 
and  myasthenia  with  diminished  secretion  are  the  most  com- 
mon diseases  of  the  stomach  which  may  produce  uric  acid 
precipitation  and  retention. 

As  with  uric  acid  in  the  uric  acid  diathesis,  so  is  it  with 
phosphoric  acid  in  phosphaturia  :  it  is  not  the  quantity,  but 
the  form,  of  the  uric  acid  and  of  the  phosphates  which  is 
important.  The  acidity  of  the  urine  is  diminished  until  it  is 
nearly  neutral,  or  neutral  or  even  alkaline,  and  the  phos- 
phates precipitate  in  it  either  spontaneously  or  on  heating. 
The  quantity  of  the  acid  phosphates  is  diminished  and  the 
quantity  of  the  neutral  and  alkaline  phosphates  is  in  excess. 
Instead  of  increased  there  is  diminished  acidity  of  the  fluids 
of  the  body,  which  is  not  incidental  to  alimentation,  though 
it  may  be  produced  and  controlled  by  it.  but  which  is  a 
chemical  condition  due  to  excessive  elimination  of  acids, 
accompanied  often  by  diminished  removal  of  alkalies  by  the 
intestines.  During  the  period  of  normal  gastric  digestion 
the  acidity  of  the  urine  is  diminished,  and  this  condition  of 
the  urine  results  from  the  withdrawal  of  acid  from  the  body 
by  gastric  secretion.  The  degree  of  change  of  the  acidity  of 
the  urine  during  digestion,  and  under  the  same  conditions,  is 
a  rough  index  of  the  amount  of  acid  secreted  by  the  stomach. 


THE    VICIOUS   CIRCLES   OF   THE   STOMACH.  62 1 

In  the  diseases  accompanied  by  subacidity  the  diminution 
of  the  acidity  of  the  urine  is  less  than  in  health,  and  in  the 
diseases  accompanied  by  superacidity  the  diminution  is 
greater  than  in  health.  If  the  superacid  gastric  secretion  be 
removed  by  vomiting  or  by  lavage,  the  diminution  is  still 
more  marked,  and  the  total  urine  of  the  twenty-four  hours 
may  be  milky  (phosphates),  alkaline,  and  poor  in  chlorids. 
Gastric  phosphaturia  is  found  in  chronic  hypersthenic  gas- 
tritis, adenohypersthenia  gastrica,  and  in  the  other  diseases  of 
the  stomach  accompanied  by  superacidity  or  by  supersecre- 
tion,  whether  they  are  or  are  not  associated  with  stagnation, 
or  retention,  or  vomiting. 


V.  INFLUENCE  ON  THE  HEART  AND   CIRCULATION. 

If  it  be  borne  in  mind  how  fine  and  complex  is  the  mechan- 
ism of  the  circulation,  how  numerous  are  the  influences  which 
control  or  alter  the  caliber  of  the  arterioles  and  the  action 
of  the  heart,  it  should  cause  no  wonder  that  the  heart  is 
frequently  disturbed  by  the  pathological  reflexes  and  the 
mechanical  compression  of  an  organ  so  closely  situated  and 
so  intimately  connected  with  it  by  an  almost  common  nerve- 
supply  as  is  the  stomach.  Normal  digestion  increases  the  fre- 
quency and  strength  of  the  heart-beats,  and  strong  excitation 
of  the  mucous  membrane  of  the  stomach  makes  the  heart's 
action  slow.  The  close  anatomical  and  physiological  rela- 
tionship would  seem  to  furnish  good  grounds  for  expecting 
the  diseased  stomach  easily  and  frequently  to  disorder  the 
heart's  action.  This  natural  expectation  is  only  in  part  ful- 
filled by  clinical  observation. 

Tachycardia  of  gastric  origin  is  so  rare  that  we  do  not 
remember  to  have  seen  a  case.  The  pulse  may  be  frequent 
in  diseases  of  the  stomach  accompanied  by  fever  or  by  an 
inflammatory  complication,  and  a  weak  heart  may  be  excited 
by  normal  or  by  pathological  digestion.  But  the  normal 
heart  beats  no  more  frequently  in  the  afebrile  or  simple  dis- 
eases of  the  stomach  than  it  does  in  health.  Moreover,  a 
symptomatic  increase  of  the  frequency  of  the  pulse  does  not 
constitute  tachycardia,  for  it  is  essential  that  the  neuromuscu- 
lar apparatus  be  disordered.  Arrhythmia,  allorrhythmia, 
and  asymmetry  are  equally  as  rare  as  gastric  tachycardia, 
though  they  may  occur  in  association  with  other  disturbances 
of  the  heart  of  undoubted  gastric  origin.  It  may  be  possible 
for  a  disease  of  the  stomach  to  produce  these  disturbances  in 


622  DISEASES  OF  THE  STOMACH. 

either  their  paroxysmal  or  habitual  forms,  but  it  would  seem 
wise  to  ignore  the  possibility  until  better  proof  of  their  causa- 
tion is  given  than  we  have  been  able  to  find.  Gastric  brady- 
cardia, however,  is  the  most  common  form  of  the  slow 
heart.  The  heart-beats  sometimes  fall  as  low  as  35  or  40 
to  the  minute,  but  the  milder  form  with  50  or  60  beats  a 
minute  is  most  frequent.  The  bradycardia  may  occur  in 
paroxysms  and  be  accompanied  by  weak  action  of  the  heart, 
as  shown  by  a  small  pulse,  pallor,  cold  extremities,  fainting, 
and  by  loss  of  consciousness  in  severe  cases  ;  it  may  be  inter- 
mittent, the  paroxysm  occurring  in  connection  with  gastric 
digestion  or  with  an  exacerbation  of  gastric  irritation  ;  or  it 
may  become  chronic  and  habitual.  It  is  sometimes  observed 
in  neurasthenia  gastrica,  but  it  is  most  common  in  myasthenia 
and  obstructive  retention,  in  ulcer,  in  the  painful  paroxysms 
of  hypersthenic  gastritis,  and  in  gastroptosis,  particularly 
when  the  gastroptosis  is  accompanied  by  retention,  by  neu- 
rasthenia, and  by  low  abdominal  tension. 

Nervous  palpitation  may  be  the  e.xpression  of  a  disease  of  the 
stomach,  and,  indeed,  in  either  its  subjective  or  its  objective 
form.  The  subjective  form  is  characterized  by  normal  heart 
action,  the  complaints  of  the  patient  being  due  to  hyperes- 
thesia of  the  sensory  nerves  of  the  heart.  This  pseudopalpi- 
tation  occurs  sometimes  in  ulcer,  adenohypersthenia  gastrica, 
chronic  hypersthenic  gastritis,  and  gastralgia,  the  epigastric 
cutaneous  nerves  being  at  the  same  time  hyperesthetic. 
Objective  palpitation  is  characterized  by  perceptible  over- 
action  of  the  heart,  the  frequency  of  the  heart-beats  being 
commonly  increased.  The  palpitation  may  have  in  the  dis- 
ease of  the  stomach  its  all-sufficient  cause  or  only  the  occa- 
sion of  the  attack.  The  diagnosis  of  the  cause  of  palpitation 
may  present  almost  insuperable  difficulties,  but  the  source  of 
the  trouble  may  be  located  in  the  stomach  by  exclusion  of 
the  diseases  of  the  heart  and  blood-vessels,  and  of  other  dis- 
eases and  habits  (morphinism,  alcoholism,  abuse  of  tobacco, 
excesses  in  venery,  etc.)  which  may  produce  it,  by  the  close 
relation  of  the  attacks  to  gastric  digestion,  and  by  its  control 
or  cure  under  treatment  of  the  disease  of  the  stomach  with 
which  it  is  associated. 

Gastrocardiovascular  Symptom-groups. — A  well-defined 
cardiovascular  symptom-group  of  gastric  origin  is  sometimes 
met  with  in  neurasthenic  or  nervous  patients,  between  the 
ages  of  twenty  and  forty  years,  who  suffer  from  bulimia, 
adenohypersthenia  gastrica,  myasthenia  gastrica,  or  neuras- 
thenia  gastrica.      The  trouble   is  always  paroxysmal   in  its 


THE   VICIOUS   CIRCLES    OF  THE   STOMACH  623 

first  stages.  The  attacks,  which  begin  and  end  suddenly, 
last  from  a  few  hours  to  two  or  three  days.  Usually,  during 
the  night  or  soon  after  rising  in  the  morning,  a  sense  of  oppres- 
sion and  fullness  is  felt  in  the  epigastrium,  the  heart  palpi- 
tates, the  pulse  becomes  irregular,  and  the  patient  is  suddenly 
seized  with  great  anxiety.  The  heart  feels  overdistended  and 
flutters,  and  the  abdominal  aorta  palpitates  strongly.  The 
patient  is  weak  and  depressed,  cardiac  dyspnea  is  marked, 
but  there  is  no  precordial  pain  and  no  headache.  The 
attacks  recur  after  varying  intervals,  or  the  trouble  may 
become  continuous  and  chronic,  with  constant  epigastric  dis- 
tention, dyspnea,  bulimia,  and  anxiety  which  is  likely  to  pro- 
duce hypochrondriasis.  The  disease  affects  almost  exclusively 
men,  and  chiefly  brain-workers,  the  attacks  recurring  after 
eating  an  acid  or  some  particular  fruit  or  food.  The  whole 
trouble  seems  to  be  produced  by  a  reflex  from  the  morbid 
mucous  membrane  of  the  stomach  affecting  the  vagosympa- 
thetic, and  probably  also  the  vasomotor,  nerves.  In  the  severe 
attacks  the  arterioles  are  constricted  and  the  left  heart  is 
dilated.  During  the  intervals  between  the  attacks  the  heart 
and  circulation  are  normal.  The  cardiovascular  paroxysms 
can  be  controlled  by  the  proper  treatment  of  the  disease  of 
the  stomach. 

Another  well-defined  gastrocardiovascular  symptom-group, 
produced  by  a  disease  of  the  stomach,  affects  the  arterioles  of 
the  lesser  circulation  and  causes  dilatation  of  the  right  side 
of  the  heart  (Potain).  These  attacks  are  more  common  in 
neurasthenic  and  chlorotic  girls  than  in  men,  and  they  may 
or  may  not  be  painful.  The  attacks  are  sometimes  brought 
on  by  very  mild  gastric  excitants,  even  solid  food,  like  diges- 
tible meats,  being  sufficient  to  produce  them.  The  attacks 
occur  during  gastric  digestion  and  begin  with  slight  dyspnea 
and  substernal  oppression.  In  the  beginning  of  the  attack 
the  second  pulmonary  sound  is  accentuated  and  has  a  quick, 
metallic  ring.  Later,  the  heart  sounds  become  muffled,  and 
a  distinct  bruit  de  galop  can  be  heard  to  the  right  of  the 
sternum.  In  the  severe  attacks  relative  tricuspid  insuffi- 
ciency may  develop,  a  systolic  murmur  being  heard  at  the 
apex,  propagated  to  the  right  and  accompanied  by  a  systolic 
distention  of  the  right  jugular  vein.  The  heart  dulness  is 
then  enlarged  to  the  right.  The  attack  may  end  in  half  an 
hour,  and  may  or  may  not  be  accompanied  by  moderately 
severe  pain  extending  over  the  thorax  from  the  left  clavicle 
to  the  umbilicus.  The  trouble  is  most  common  in  hyper- 
esthesia gastrica,  neurasthenia  gastrica,  during  the  develop- 
ment of  gastroptosis,  and  in  adenohypersthenia  gastrica. 


624  DISEASES  OF  THE   STOAfACH. 

The  influence  of  the  diseases  of  the  stomach  on  the  heart 
and  blood-vessels  should  not  be  forgotten,  for  the  gastro- 
cardiovascular  troubles  can  be  cured  only  by  the  proper 
treatment  of  the  disease  of  the  stomach.  An  acute  disease 
of  the  stomach  or  an  exacerbation  of  a  chronic  disease  of  the 
stomach  may  break  compensation,  or  give  the  death-stroke 
in  organic  disease  of  the  heart,  or  be  the  exciting  cause  of  an 
attack  of  angina  pectoris.  It  is  a  good  rule  to  watch  the 
stomach  in  the  management  of  the  diseases  of  the  heart  and 
blood-vessels. 


VI.  INFLUENCE  ON  THE  NERVOUS  SYSTEM. 

During  normal  gastric  digestion  the  nervous  system  is 
physiologically  in  repose.  It  is  a  natural  period  of  mental 
and  physical  rest.  The  inactivity  may  be  prevented  by  the 
use  of  stimulants,  like  tea,  coffee,  alcohol,  tobacco,  and  by  a 
lively  environment.  But  if  the  mind  be  not  forced  into 
activity,  it  will  seek  its  physiological  repose,  and  if  it  be  too 
much  excited  artificially,  the  functions  of  the  stomach  may 
be  slowly  performed.  In  an  analogous  manner,  pathological 
digestion  may  destroy  this  natural  tendency  of  the  mind  and 
body,  and  the  nervous  system  itself  may  manifest  the  dis- 
ordered digestion.  Gastric  headache,  drowsiness,  insomnia, 
and  the  many  nervous  symptoms  of  the  diseases  of  the 
stomach,  display  the  influence  of  the  diseased  stomach  on 
the  nervous  system.  But  not  only  are  nervous  symptoms 
produced,  but  also  special  disorders  of  the  nervous  system. 
The  principal  disturbances  of  this  kind  are  neurasthenia,  ver- 
tigo, tetany,  and  epileptiform  convulsions. 

There  is  no  question  in  our  mind  that  both  spinal  and 
cerebral  neurasthenia  may  result  from  the  diseases  of  the 
stomach.  There  is  no  doubt  that  the  reverse  is  equally  true  ; 
that  neurasthenia  may  begin  in  other  organs  or  in  the  central 
nervous  system  and  extend  to  the  stomach.  Irritable  nerve 
weakness  may  readily  be  propagated  from  one  division  of  the 
sympathetic  system  to  another.  Then  are  established  the 
neurasthenic  vicious  circles  of  the  stomach,  and  the  stomach 
itself  may  forge  this  circular  chain.  It  matters  not  whether 
the  irritable  weakness  be  caused  by  self-poisoning,  by  subnu- 
trition,  by  oligocythemia  (gastric),  by  direct  propagation  along 
the  sympathetic  or  the  pneumogastric  nerves,  or  by  the  effect 
of  the  gastric  trouble  on  the  mind  or  on  sleep.  The  stomach 
is  still  the  creator  of  the  trouble.    The  diseases  of  the  stomach 


THE   VICIOUS   CIRCLES  OF  THE   STOMACH.  625 

which  are  most  active  in  this  respect  are  neurasthenia 
gastrica,  gastroptosis,  myasthenia  gastrica  (with  hyper- 
esthesia, hyperchlorhydria,  or  fermentation),  obstruction  of 
the  pylorus,  and  all  the  hypersthenic  painful  affections  of  the 
stomach.  The  disease  of  the  stomach  is  the  primary  trouble, 
and  the  secondary  neurasthenia  can  be  cured  only  after  the 
control  or  cure  of  the  exciting  causative  disease.  Like  other 
secondary  diseases,  the  neurasthenia  may  acquire  an  inde- 
pendent existence,  and  it  always  requires  treatment  in  itself. 
But  this  peculiarity  is  no  evidence  against  its  genesis  by  the 
disease  of  the  stomach. 

Vertigo  a  stomacho  laeso  (Trousseau)  is  not  frequent.  Gas- 
tric vertigo  is  in  itself  without  characteristic  features,  but  it 
occurs  in  association  with  the  stomach  trouble  and  is  relieved 
by  the  cure  of  the  stomach  disease.  It  is  sometimes  possible 
to  bring  it  on  by  sudden  change  of  position,  and  to  relieve  it 
by  giving  a  few  mouthfuls  of  food ;  it  is  sometimes  associ- 
ated with  nausea,  sometimes  with  frontal  headache,  sometimes 
with  vasomotor  disturbances,  and  sometimes  with  hot  flushes 
and  a  sense  of  warmth  in  the  stomach.  The  attacks  begin 
sometimes  when  the  stomach  is  empty,  and  sometimes  a  few 
hours  after  a  meal.  The  head  first  feels  light,  or  heavy,  or 
compressed,  the  vision  becomes  cloudy,  there  is  some  partic- 
ular sensation  referable  to  the  stomach,  and  then  the  sur- 
rounding objects  oscillate  and  turn  about  the  patient,  or  the 
patient  loses  his  sense  of  equilibrium  and  of  space  and  feels 
himself  in  the  air.  Consciousness,  however,  is  never  lost, 
and  the  patient  always  knows  that  the  movements  are  mere 
illusions.  Vertigo  is  a  very  common  symptom,  and  it  is  a 
symptom  of  many  other  diseases  (particularly  of  the  arteries 
and  the  circulation)  besides  those  of  the  stomach.  In  the 
cases  of  vertigo  in  which  we  have  been  able  to  find  no  other 
cause  than  the  disease  of  the  stomach,  the  digestion  has 
always  been  "  slow  and  laborious  "  (Trousseau),  and  the  myas- 
thenia has  been  accompanied  by  butyric  acid  fermentation. 
But  we  are  not  prepared  to  state  that  gastric  vertigo  may  not 
occur  under  other  circumstances. 

Tetany  is  a  rare  complication  of  the  diseases  of  the  stomach, 
and  we  have  been  able  to  find  only  41  reported  cases. 
But  gastric  tetany  is  frequently  fatal  (73  per  cent.),  and 
many  cases  doubtless  occur  without  being  recognized  or 
without  being  reported. 

Tetany  is  a  motor  neurosis  characterized  by  bilateral  par- 
oxysmal tonic  spasms  affecting  chiefly  the  flexor  muscles  of 
the  extremities.     The  muscular  cramps  are  painful,  and  con- 
40 


626  DISEASES  OF  THE  STOMACH. 

sciousness  is  never  (true  tetany)  or  very  seldom  (sometimes  in 
gastric  tetany)  lost.  The  mind  remains  clear  (true  tetany)  or 
there  may  be  some  confusion  of  the  intellect  and  a  treach- 
erous memory  (sometimes  in  gastric  tetan)').  There  is  no 
fever  unless  there  be  a  febrile  complication,  and  the  attacks, 
which  last  for  from  five  to  twenty  minutes,  or  possibly  several 
hours,  begin  and  end  suddenl)',and  are  preceded  and  followed 
by  sensory  disturbances,  like  formication,  over  the  region  of 
the  affected  muscles.  After  intermissions  the  paroxysms  may 
recur,  and  the  trouble  may  last  for  several  days  or  weeks. 

Gastric  tetany  occurs  in  a  mild  and  in  a  severe  form.  In  the 
mild  form  the  cramps  affect  the  muscles  of  the  extremities, 
sometimes  of  the  upper  extremities  only,  and  are  confined 
chiefly  to  the  flexor  muscles  of  the  forearms  and  hands  and 
to  the  corresponding  muscles  of  the  legs  and  feet.  The 
extensor  muscles  are  also  affected,  and,  while  yielding  to  the 
stronger  flexors,  aid  in  holding  the  hand  rigid  and  immovable 
through  the  influence  of  the  will.  A  characteristic  deformity 
of  the  hands  was  described  by  Trousseau  as  the  "  obstet- 
rician's hand."  The  thumb  is  strongly  adducted,  the  straight 
finsfers  are  drawn  against  one  another  and  are  half  flexed  over 
the  thumb  at  the  metacarpophalangeal  joint,  and  the  sides  of 
the  palm  are  turned  in  to  form  a  cone.  The  index  finger  may 
be  flexed  to  a  greater  extent  than  the  others,  or  the  thumb 
alone  may  be  contractured.  Frequently,  however,  the  hand 
assumes  the  same  form  as  in  posthemiplegic  contracture. 
The  toes  are  contracted  in  an  analogous  manner,  and  the  foot 
is  commonly  in  the  equinus  position.  The  hands  are  flexed 
on  the  wrist,  the  arms  and  legs  at  the  elbows  and  knees,  and 
the  upper  arms  and  thighs  may  be  fixed  in  strong  adduction  ; 
but  these  contractures  may  not  occur  in  the  mild  form.  In 
the  severe  form  the  cramps  begin  in  the  extremities  and 
extend  to  the  thorax  and  abdomen  ;  they  may  sometimes 
affect  the  diaphragm,  the  muscles  of  the  neck,  of  the  face,  of 
the  eyes,  of  the  tongue,  of  the  pharynx,  and  of  the  larynx. 
The  pulse  is  rapid,  and  the  patient  may  lose  his  life  by 
suffocation. 

The  tendon  reflexes  are  normal,  or  are  not  changed  in  a 
particular  manner,  but  the  skin  reflexes  are  exaggerated. 
Compression  of  the  main  nerve  of  the  extremity  (median, 
sciatic)  or  compression  of  the  main  artery  or  vein  of  the 
extremity,  increases  the  spasm  during  the  stage  of  contracture 
and  excites  an  attack  during  the  intermission.  It  is  curious  to 
note  that  the  effect  of  the  compression  is  reflected  to  the  cor- 
responding extremity  (Trousseau).     The  galvanic  excitability 


THE   VICIOUS   CIRCLES   OF   THE   STOMACH.  627 

of  the  motor,  and  sometimes  of  the  sensory,  nerves  (except 
the  facial  nerve)  during  the  continuation  of  the  trouble  is 
always  greatly  increased,  and  usually  the  faradic  current  pro- 
duces the  same  effect  as  the  galvanic  current  (Erb).  The 
mechanical  irritability  of  the  nerves  is  increased  (Trousseau), 
and  Chvostek  discovered  that  it  is  possible  to  produce  con- 
traction of  the  facial  muscles  by  tapping  over  the  facial  nerve 
or  by  stroking  the  skin  and  muscles  of  the  face  from  above 
downward,  along  a  line  extending  from  a  point  midway 
between  the  eye  and  ear  to  the  middle  of  the  horizontal 
branch  of  the  lower  jaw.  These  signs  of  Trousseau,  of  Erb, 
and  of  Chvostek  are  present  in  only  a  part  of  the  cases  of 
gastric  tetany,  and  their  absence  constitutes  an  important 
variation  from  true  tetany. 

Gastric  tetany  and  tetany-like  cramps  result  from  a  very 
limited  number  of  the  diseases  of  the  stomach.  And,  indeed, 
when  these  attacks  do  occur,  they  can  not  be  considered  a 
result  of  the  primary  disease  of  the  stomach,  but  of  a  special 
secondary  condition,  which  represents  an  episode  in  the  devel- 
opment of  the  primary  disease.  It  is  neither  ulcer,  nor 
obstruction  of  the  pylorus,  nor  gastroptosis,  nor  myasthenia, 
nor  chronic  hypersthenic  gastritis  which  directly  cause  the 
attacks,  but  it  is  the  gastric  retention  that  is  the  essential 
condition.  In  the  majority  of  the  cases  the  gastric  retention 
is  associated  with  excessive  secretion  or  with  a  highly  acid 
condition  of  the  gastric  juice.  In  a  small  percentage  of  the 
cases  the  retention  is  accompanied  by  active  fermentation  and 
by  the  absence  of  free  hydrochloric  acid.  The  retention  need 
not  be  continuous,  for  it  may  be  absent  before  and  after  the 
attacks  ;  but  whether  the  retention  be  continuous,  or  only 
temporary  or  accidental,  it  is  a  condition  essential  to  the 
occurrence  of  the  attacks.  The  continuity  of  secretion  is  the 
effect  of  the  retention ;  the  hydrochloric  acidity  of  the  con- 
tents is  a  manifestation  of  the  diseased  mucous  membrane ; 
and  the  organic  acidity  is  the  result  of  the  retention  and  of 
the  quality  of  the  diet.  The  frequency  of  butyric  fermenta- 
tion in  these  cases  is  noteworthy  and  suggestive.  The 
immediate  exciting  cause  of  the  attacks  may  be  a  vaginal 
examination,  or  palpation  of  the  stomach,  or  the  introduc- 
tion of  the  tube,  or  lavage,  or  the  sudden  evacuation  of  the 
contents  of  the  stomach  through  the  tube  or  by  vomiting,  or 
the  attacks  may  be  caused  by  other  forms  of  mechanical  irri- 
tation. The  attacks  may  be  produced  by  auto-intoxication, 
or,  as  some  contend,  by  reflexes  from  the  stomach,  or  by  the 
extreme  poverty  of  the  tissues  (muscle  and  nerve)  in  water. 


628  DISEASES  OF  THE  STOMACH. 

It  seems  probable  that  the  reflexes  and  the  desiccation  are 
only  contributing  causes. 

Kussmaul  may  be  considered  the  father  of  the  desiccation 
theory,  but  he  has  recently  abandoned  it.  There  is  no  ques- 
tion that  as  a  result  of  the  retention  of  the  excessive  secretion, 
of  the  diminished  absorption,  and  of  the  vomiting  the  system 
is  deprived  of  much  water.  As  a  consequence  there  is  oli- 
gemia sicca,  very  dry  skin,  hard  feces,  and  a  small  quantity 
of  urine,  but  the  blood  is  not  thickened,  as  is  sometimes  stated. 
Indeed,  it  is  poor  in  albumin,  poor  in  sodium  chlorid,  and  the 
number  of  corpuscles  in  the  cubic  millimeter  is  diminished, — 
certainly  not  increased, — and  there  may  be  signs  of  excessive 
destruction  of  the  red  corpuscles,  and  of  degeneration  and 
decrease  of  the  number  of  white  corpuscles.  But  the  rectal 
administration  of  water  or  of  salt  solution  does  not  prevent  or 
control  the  attacks  ;  water  starvation  and  excessive  water 
elimination  do  not  produce  them,  and  the  attacks  do  not 
occur  in  relation  to  the  poverty  of  the  system  in  water.  It  is 
easily  conceivable  how  the  desiccation  and  the  changes  of  the 
blood  may  stimulate  the  absorption  of  the  poisons  which  may 
be  in  the  stomach,  may  favor  their  formation  in  the  body,  and 
may  lead  to  their  accumulation  in  the  system  by  insufficient 
elimination. 

There  is  little  evidence  of  the  production  of  these  muscular 
cramps  by  reflex  action.  Mechanical  irritation  may  occasion 
them,  but  just  as  readily  when  other  parts  of  the  body  are  irri- 
tated as  when  the  irritation  acts  directly  on  the  mucous  mem- 
brane or  on  the  wall  of  the  stomach.  Tetany,  due  to  intestinal 
worms,  is  more  likely  toxic  than  reflex.  Reflex  action  is  the 
cloak  in  which  ignorance  loves  to  hide  itself  The  theory  of 
reflex  action  naturally  e.xcites  distrust,  and  there  seems  to  be 
no  clinical  nor  experimental  evidence  in  its  favor. 

It  seems  probable  that  the  attacks  of  tetany  and  of  tetany- 
like  cramps  are  due  to  self-poisoning.  Bouveret  and  Fleiner 
have  extracted  from  the  gastric  contents  toxins  capable  of 
producing  convulsions  and  death  of  the  animal,  but  the  con- 
vulsions were  clonic.  The  extract  of  Bouveret  and  Devic 
has  been  shown  to  be  a  mixture  containing  a  yellow  substance 
capable  of  producing  mydriasis  and  vasoconstriction,  but  it  is 
found,  like  the  ethylendiamin  of  Kulneff",  in  cases  with  no 
convulsions  of  any  kind.  It  has  also  been  shown  by  Fleiner 
that  the  alcoholic  extract  is  poisonous  when  the  neutralized 
contents  are  not  toxic.  Bouveret  and  Devic  suggest  that  the 
poison  may  be  formed  in  the  stomach  by  the  digestive  action 
of  free  HCl  in  the  presence  of  alcohol  (swallowed  or  gener- 


THE   VICIOUS   CIRCLES   OF   THE   STOMACH.  629 

ated  by  fermentation).  It  has  also  been  suggested  that  the 
poison  may  be  formed  by  prolonged  gastric  digestion  (pepto- 
toxin)  and  may  be  absorbed  slowly  and  continuously  and 
without  special  alteration  by  the  diseased  or  healthy  mucous 
membrane.  Ewald  and  Jacobson  extracted  the  picrate  of  an 
alkaloid-like  body  from  the  urine  of  a  tetany  patient,  and 
Albu  found  a  double  gold  and  platinum  alkaloidal  salt  in  the 
urine  during  the  attack  which  was  absent  from  the  urine  in 
the  interval.  Consequently,  we  may  conclude  that  there  is 
no  chemical  nor  experimental  evidence  in  favor  of  the  intoxi- 
cation theory,  for  a  poison  capable  of  producing  the  tetany-like 
cramps  has  not  been  found  in  the  stomach  contents  before 
and  during  the  attacks,  nor  in  the  blood  during  the  attacks, 
nor  in  the  urine  during  and  after  the  attacks.  These  failures 
exclude  the  probability  of  acute  self-poisoning,  but  do  not 
refute  the  hypothesis  of  a  slow  cumulative  poisoning.  The 
evidence  in  favor  of  the  auto-intoxication  theory  is  chiefly 
clinical.  The  cramp-producing  agent  acts  like  an  alkaloidal 
poison  and  produces  no  anatomical  lesion  except  nephritis 
(toxic)  in  some  cases.  Tetany,  so  far  as  at  present  known,  is 
always  toxic,  occurring  in  the  course  of  or  during  the  sub- 
sidence of,  infectious  diseases,  after  the  extirpation  of  the  thy- 
roid gland  (mucin-toxemia),  after  the  administration  of  certain 
chemicals  or  drugs,  and,  sometimes,  during  pregnancy  or  lac- 
tation. And  gastric  and  tetany-like  cramps  occur  in  close 
causal  relation  with  gastric  retention,  the  gastric  contents  con- 
taining a  mixed  and  active  virulent  germ  growth. 

The  convulsicms  which  result  from  a  disease  of  the  stom- 
ach may  be  epileptiform.  After  a  sensation  of  weight  or  of 
painful  dragging  of  the  stomach,  of  nausea,  or  of  regurgita- 
tion, general  tonic,  followed  by  clonic,  convulsions  begin,  and 
are  accompanied  by  loss  of  consciousness.  The  gastric 
epileptiform  attacks  should  be  distinguished  from  true 
epilepsy  with  a  gastric  aura,  and  they  may  occur  as  the  only 
convulsive  manifestation  of  the  gastric  disease,  or  they  may 
occur  in  a  patient  who  has  attacks  of  tetany-like  cramps. 
Explanations  of  the  production  of  the  cortical  irritation  are 
hypothetical,  and  the  prognosis  is  better  than  in  true  epilepsy 
and  in  gastric  tetany. 


VII.  INFLUENCE  ON  THE  SKIN. 

Through  the  influence  of  the  diseases    of  the   stomach  on 
the  vasomotor  nerves  and  on  nutrition,  and  through  the  irri- 


630  DISEASES  OF  THE  STOMACH. 

tation  produced  by  the  elimination  of  the  products  of  self- 
poisoning,  the  skin  may  become  diseased.  No  doubt  intesti- 
nal diseases  are  more  active  in  the  causation  of  diseases  of 
the  skin  than  are  the  diseases  of  the  stomach,  but  in  some 
cases  the  stomach  is  the  sole  source  of  the  skin  trouble. 
Urticaria  is  popularly  supposed  to  be  due  to  a  bad  stomach. 
A  fugacious  form  often  results  from  the  eating  of  berries  or 
shell-fish,  and  it  is  difficult  to  determine  whether  this  angio- 
neurosis  is  produced  by  reflex  action  or  by  self-poisoning. 
The  fugacious  and  chronic  forms  are  most  common  in  chil- 
dren, as  a  result  of  the  acute  or  chronic  myasthenia  induced 
by  overfeeding.  Urticaria  may  also  result  from  gastric  fer- 
mentation in  the  adult,  but,  in  our  observation,  the  urticaria 
is  accompanied  in  nearly  all  cases  of  gastro-intestinal  origin 
by  intestinal  putrefaction  and  indicanuria. 

Eczema  is  very  rare  as  a  result  of  a  disease  of  the  stomach 
alone,  but  it  may  be  excited  by  acid  self-poisoning  (fermenta- 
tion) in  patients  predisposed  to  it,  and  the  excessive  acidity 
of  the  system  may  be  the  cause  of  the  obstinacy  of  certain 
cases  to  treatment.  We  have  noticed  that  eczema  seborrhcei- 
cum  is  nearly  always  associated  with  butyric  acid  fermenta- 
tion in  the  stomach  or  the  formation  of  y3-oxybutyric  acid 
in  the  body.  The  "  red  nose  "  (rosacea)  is  sometimes  due  to 
myasthenic  fermentation  and  to  the  diseases  accompanied 
by  hyperchlorhydria.  The  influence  of  the  diseases  of  the 
stomach  in  the  causation  of  the  diseases  of  the  skin  has  not 
been  thoroughly  studied,  and  it  presents  an  opportunity  for 
the  emplo\'ment  of  modern  methods  in  the  correction  of 
errors  and  in  the  extension  of  our  knowledefe. 


VIll.  INFLUENCE  ON  THE  KIDNEYS. 

The  diseases  of  the  stomach  modify  directly  the  composi- 
tion of  the  urine.  In  retention  the  total  quantity  of  the 
urine  maybe  reduced  to  one-fifth  of  the  normal  quantity.  Its 
acidity  may  be  increased  (diminished  gastric  secretion)  or  it 
may  be  decreased  (excessive  secretion).  There  may  be  phos- 
phaturia,  or  there  may  be  precipitation  of  uric  acid,  or  the 
toxicity  of  the  urine  may  be  increased.  Functional  albu- 
minuria is  frequently  caused  by  the  diseases  of  the  stomach 
which  produce  supersecretion  and  phosphaturia.  And,  finally, 
the  urine  may  contain  gastric  ferments  and  albumoses.  But 
it  is  doubtful  whether  these  changes  do  much  direct  damage 


THE   SECONDARY  DISEASES  OF   THE   STOMACH.       63  I 

to  the  kidneys  by  their  local  action  alone,  with  the  exception, 
possibly,  of  the  unassimilable  albumin. 

But  indirectly,  by  their  influence  on  the  liver,  on  the  blood, 
on  the  cardiovascular  system,  and  on  the  nourishment  of  the 
body,  the  diseases  of  the  stomach  may  initiate  changes  in  the 
glomeruli  and  the  tubules.  The  process  may  be  degenera- 
tive, congestive,  or  inflammatory.  Chronic  degeneration  may 
result  from  subnutrition  in  conjunction  with  auto-intoxication. 
The  epithelium  lining  the  cortex  tubes  is  swollen  and  infil- 
trated with  granular  matter  and  fat.  There  is  little  albumin 
in  the  urine,  and  only  a  few  casts  (there  being  no  changes  in 
the  blood-vessels  or  in  arterial  tension,  no  hypertrophy  of  the 
left  ventricle,  and  no  uremia),  the  patient's  strength  and  nutri- 
tion gradually  or  progressively  failing.  But  besides  the 
chronic  degeneration,  an  exudative  or  even  productive  inflam- 
mation of  the  glomeruli  or  of  the  cortex  tubes  may  result 
indirectly  from  the  diseases  of  the  stomach.  The  diseases  of 
the  stomach  undoubtedly  influence  the  evolution  of  chronic 
nephritis,  and  a  therapeutic  rule  may  be  drawn  from  this 
clinical  fact.  But  the  part  which  the  diseases  of  the  stomach 
play  in  the  causation  of  the  diseases  of  the  kidneys  is  not 
definitely  known,  and  it  is  very  likely  that  their  pathogenic 
influence  may  easily  be  exaggerated. 


CHAPTER    II. 
THE  SECONDARY  DISEASES  OF  THE  STOMACH. 

The  secondary  diseases  of  the  stomach  are  produced  by 
the  diseases  of  a  large  number  of  other  organs,  and,  as  a  rule, 
but  not  always,  bear  no  marks  which  would  reveal  or  suggest 
their  origin.  When  once  established,  they  are  capable  of  an 
independent  existence,  and  may  have  their  usual  evolution. 
They  may,  however,  be  more  obstinate  than  is  ordinarily  the 
case,  and  their  cure  requires  the  cure  or  control  of  the  causa- 
tive disease  or  its  natural  advance  to  another  stage  in  which 
it  has  not  the  same  influence  on  the  stomach. 

The  disease  of  the  stomach  may  be  an  accidental  associa- 
tion, developing  before  the  beginning  or  during  the  course  of 
the  disease  of  the  other  organ,  and  as  the  effect  of  the  same  or 
of  totally  different  causes.  They  exist  together,  but  the  one 
is  not  produced  by  the  other. 


632  DISEASES  OF  THE  STOMACH. 

In  order  that  tlie  disease  of  the  stomach  be  considered 
secondary,  it  must  be  connected  in  its  origin  and  evolution 
with  a  primary  disease.  What  precedes  can  not  be  a  result. 
Its  course  must  be  influenced  by  the  primary  disease,  and  it 
must  be  observed  to  follow  the  primary  disease  with  sufficient 
frequency  to  be  considered  an  order  of  sequence.  Naturally, 
the  probability  of  the  etiological  relation  is  greater  when  an 
explanation  can  be  given  of  the  mode  of  genesis. 

In  order  to  throw  light  on  the  often  obscure  relation,  it  is 
necessary  to  know  the  age  and  nature  of  the  stomach  trouble 
with  more  exactness  than  can  be  learned  from  the  clinical 
history,  from  the  physical  signs,  and  from  autopsies.  Dis- 
eases of  the  stomach  are  too  often  latent,  are  too  often 
ill-defined  or  similar  in  their  subjective  manifestations,  too 
often  escape  a  physical  search,  too  often  leave  no  traces  per- 
ceptible after  death,  and  too  often  change  their  nature  during 
their  terminal  period,  to  have  their  age  and  nature  revealed 
without  the  use  of  the  modern  methods  of  examination. 


1.  DISEASES  OF  THE  INTESTINES. 

Clinical  observation  establishes  the  fact  that  a  disease 
(except  obstruction)  of  one  of  the  divisions  of  the  diges- 
tive tube  affects  the  divisions  of  the  alimentary  tract  below  it 
much  more  frequently  than  those  above  it.  Consequently, 
secondary  disease  of  the  stomach  does  not  often  result  from 
intestinal  disease,  although  the  stomach  is  not  exempt  from 
intestinal  pathogenic  influences. 

Symptomatic  disturbances — loss  of  appetite,  nausea,  vomit- 
ing, excessive  or  diminished  secretion — of  the  stomach  are 
very  common  in  diseases  of  the  intestines.  Active  abdominal 
plethora  may  result  from  the  active  hyperemia  of  intestinal 
irritation  or  inflammation.  Active  plethora  is  as  frequent  as 
portal  congestion,  and  in  this  manner  intestinal  disease  may 
pro(luce  congestion  of  the  stomach  or  gastritis. 

Duodenal  obstruction  or  chronic  stenosis  in  the  upper 
intestinal  tract  may  produce  gastric  retention  and  secondary 
dilated  hypertrophy  of  the  stomach.  If  the  obstruction  is 
below  the  opening  of  the  common  duct,  there  is  regular  reflux 
of  bile  and  of  pancreatic  juice  into  the  stomach,  and  there  is 
accompanying  hyperchlorhydria  or  hypochlorhydria  accord- 
ing to  the  functional  power  of  the  gastric  glands.  In  intesti- 
nal obstruction  there  is  antiperistalsis  and  excessive  gastro- 


THE   SECONDARY  DISEASES  OF   THE   STOMACH.       633 

intestinal  secretion  above  the  obstruction,  with  nausea,  vomit- 
ing, and  hydrothionemia. 

Intestinal  auto-intoxication  may  produce  paroxysmal  or 
digestive  adenohypersthenia  gastrica.  The  paroxysmal 
attacks  may  be  very  severe — nausea,  vomiting,  cramps,  severe 
headache,  anxiety,  depression  of  spirits,  collapse,  and  even 
stupor.  The  stools  are  very  foul,  there  are  H2S  flatus 
and  indicanuria,  and  sometimes  H2S  can  be  detected  in  the 
breath  and  in  the  urine.  Chronic  intestinal  auto-intoxication 
may  produce  chronic  gastritis  by  its  direct  and  indirect  influ- 
ences. 

Intestinal  neurasthenia  and  the  hypersthenic  chronic  affec- 
tions of  the  intestines  may  produce  neurasthenia  gastrica,  and 
duodenitis  may  extend  by  continuity  of  structure  to  the  gastric 
mucous  membrane.  Enteroptosis,  also,  may  produce  gastrop- 
tosis,  but  in  our  opinion  the  particular  pathological  influence 
of  enteroptosis  has  been  somewhat  exaggerated  by  Glenard. 
The  enteroptosis  is  as  frequently  the  result  as  it  is  the  cause 
of  the  displacements  of  the  other  abdominal  organs,  and  all 
these  displacements  are  more  frequently  the  result  of  a  com- 
mon cause — emaciation  and  lack  of  proper  support. 


11.  DISEASES  OF  THE  LIVER. 

In  the  diseases  of  the  liver  secondary  diseases  of  the 
stomach  are  common  and  have  not  received  the  study  and 
recognition  which  their  frequency  and  clinical  importance 
demand. 

The  chemistry  of  digestion  may  be  disturbed  by  the  reflux 
of  bile  into  the  stomach,  which  may  excite  excessive  secre- 
tion, nausea,  and  vomiting.  In  all  our  cases  of  chronic  reflux 
of  bile  into  the  stomach  there  has  been  constant  hyperchlor- 
hydria,  and  such  is  probably  the  rule,  unless  there  be  ante- 
cedent asthenic  gastritis  or  gastric  atrophy. 

Simple  enlargement  of  the  liver  may  produce  vertical  dis- 
placement of  the  stomach  and  interfere  with  the  performance 
of  its  motor  work.  Obstructive  stagnation  is  not  seldom  pro- 
duced in  this  manner,  the  evacuation  of  the  stomach  having 
been  delayed  in  a  little  more  than  half  of  our  cases,  accom- 
panied by  noteworthy  enlargement  of  the  liver  from  various 
causes. 

In  catarrhal  icterus  and  in  infectious  cholangitis  hyper- 
chlorhydria  is  the  rule,  and  in  only  a  few  of  our  cases  have 
we  found  secretion  normal.     But  we  have  studied   too  few  of 


634  DISEASES  OF  THE   STOMACH. 

these  cases  to  do  more  than  emphasize  the  desirability  of 
further  investigations. 

Hypertrophic  cirrhosis  produces  hyperchlorhydria  with 
more  or  less  stagnation  (13  of  18  cases).  The  chronic  hyper- 
sthenic gastritis  (9  of  18)  may  have  been  due  to  the  same 
cause  as  the  hypertrophic  cirrhosis,  but  it  is  important,  at 
least,  to  remember  the  frequency  of  the  association.  In 
severe  cases  of  atrophic  cirrhosis  we  have  always  found 
hypochlorhydria,  the  result  probably  of  portal  congestion  or 
of  chronic  gastritis. 

It  is  often  stated  that  hyperchlorhydria  is  an  important 
differential  sign  between  gastric  ulcer  and  cholelithiasis.  We 
have  found  hyperchlorh\-dria  in  17  of  23  cases  of  gall- 
stones, and  3  of  the  6  remaining  ones  had  chronic  asthenic 
gastritis.  Hyperchlorhydria  occurs  as  frequently  in  chole- 
lithiasis as  in  ulcer,  but  in  5  of  the  17  cases  it  disappeared 
in  the  interval  between  the  attacks.  The  hyperchlorhydria 
is  cured  by  the  passage  or  removal  of  the  stone,  and  its  per- 
sistence after  an  attack  of  gall-stone  colic  should  exxite  sus- 
picion of  stones  still  remaining  in  the  ducts  or  in  the  gall- 
bladder. 

Pyloric  or  duodenal  stenosis  may  result  from  carcinoma 
of  the  gall-bladder  or  from  gall-stones.  The  inflammatory 
complications  of  gall-stones  may  produce  cicatricial  obstruc- 
tion, but  the  pylorus  may  also  be  obstructed  by  the  presence 
of  a  gall  stone  in  the  common  duct.  If,  under  such  circum- 
stances, there  be  gastric  retention,  pain,  vomiting,  and  super- 
secretion,  ulcer  with  pyloric  obstruction  would  probably  be 
the  diagnosis  erroneously  made.  Or  if  there  be  pain, 
vomiting,  gastric  stagnation  or  retention,  emaciation,  and 
absence  of  free  HCl,  carcinoma  would  be  suspected,  and  the 
erroneous  suspicion  would  become  a  belief  if,  as  often  hap- 
pens, a  tumor  (the  stone)  should  be  felt  in  the  pyloric  region. 


III.  DISEASES  OF  THE   HEART  AND   ARTERIES. 

So  long  as  the  valvular  diseases  of  the  heart  are  compen- 
sated the  functions  of  the  stomach  are  not  disturbed  by  them 
in  any  manner,  and  the  heart  ma}'  become  moderately  or 
temporarily  insufficient  without  producing  an  appreciable  or 
more  than  evanescent  diminution  of  secretion.  But  in  the 
asystolic  stage  of  chronic  valvular  disease  the  passive  con- 
gestion of  the  stomach  causes  secretion  to  become  insuffi- 
cient or  the  free  hydrochloric  acid  may  entirely  disappear 


THE  SECOXDAR  Y  DISEASES  OF  THE  STOMACH.         635 

from  the  contents  obtained  after  the  test-breakfast.  If  gas- 
tritis has  not  resulted  from  the  congestion  of  the  stomach, 
the  secretion  will  become  normal  after  the  integrity  of  the 
circulation  is  restored  by  proper  medication.  If  gastritis,  on 
the  other  hand,  has  been  produced,  the  gastric  secretion  will 
be  permanently  under  the  influence  of  the  anatomical  changes 
of  the  mucous  membrane.  After  cyanosis  and  dropsy  are 
well  established,  no  medication,  in  our  experience,  restores  the 
lost  or  impaired  secretion.  The  examination  in  18  cases 
during  the  period  of  compensation  revealed  no  disease  of 
the  stomach  nor  disturbance  of  secretion  which  could  not 
be  readily  explained  by  the  action  of  other  causes  than  the 
disease  of  the  heart.  In  compensated  heart  disease  gas 
often  accumulates  in  the  stomach,  although  secretion  be  nor- 
mal and  no  signs  of  fermentation  can  be  detected.  Seven  of 
these  18  cases  complained  greatly  of  the  flatulency.  Twenty- 
three  cases  examined  when  the  signs  of  heart  insufficiency 
were  marked  showed  normal  secretion  (5),  diminished  secre- 
tion (13),  and  the  complete  absence  of  free  HCl  (5).  The 
ferments  do  not  diminish  so  rapidly  as  the  free  HCl,  and  in 
none  of  the  cases  of  valvular  disease  examined  by  us  during 
the  stage  of  broken  compensation  have  we  found  hyper- 
chlorhydria   or  myasthenia. 

Arteriosclerosis  and  cardiosclerosis,  or  aortic  valvular  dis- 
ease secondary  to  chronic  disease  of  the  arteries,  produce 
three  forms  of  stomach  trouble.  In  eleven  cases  we  found  the 
digestion  of  the  test-breakfast  normal,  but  there  was  no  free 
HCl  after  the  Riegel  test-dinner,  albumin  digestion  being  pro- 
portionately defective.  The  stomach  is  capable  of  doing  a 
small  task,  but  soon  becomes  exhausted  if  prolonged  work  is 
required  of  it.  Again,  we  have  observed  six  cases  of  arterio- 
sclerosis which  presented,  from  time  to  time,  a  peculiar  form 
of  gastralgia  or  gastrospasm.  These  attacks  occur  during 
the  digestion  of  a  meal  (usually  large  and  somewhat  excitant 
in  its  physiological  action),  and  resemble  the  muscle  cramps 
of  arteriosclerosis.  It  is  probable  that  they  are  due  to  anemia, 
produced  by  the  gastric  localization  of  the  arteriosclerosis, 
and  are  not  associated  in  any  regular  manner  with  disturb- 
ances of  secretion.  Again,  arteriosclerosis  may  produce 
chronic  interstitial  and  atrophic  gastritis  (eight  cases),  and  it 
is  a  noteworthy  fact  that  this  form  of  secondary  gastritis  is 
sometimes  accompanied  by  motor  insufficiency.  The  relative 
secretory  insufficiency,  the  digestive  gastrospasm,  and  the 
mixed  gastritis  may  develop  at  different  periods  during  the 
course  of  the  arterial  disease.     In  only  three  of  the  cases  of 


636  J)ISEASES  OF  THE   STOMACH. 

well-marked  arteriosclerosis  thoroughly  studied  by  us  have 
we  found  the  stomach  normal,  but  in  some  of  the  cases  (which 
have  been  excluded  from  consideration)  the  chronic  gastritis 
was  in  all  probability  due  to  the  medication  or  to  the  ad- 
vanced nephritis. 

IV.  DISEASES  OF  THE  BLOOD. 

The  diseases  of  the  white  corpuscles  (pathological  leukocy- 
tosis, leukemia,  and  leukopenia)  do  not  produce  any  special 
disturbances  of  the  stomach.  The  enlarged  spleen  which 
accompanies  leukemia  may  be  the  cause  of  vomiting.  The 
enlarged  liver  may  obstruct  the  venous  circulation  of  the 
stomach,  and  interfere  with  the  proper  performance  of  its 
mechanical  work.  Leukemia  may,  however,  produce  symp- 
tomatic gastric  hemorrhage.  Leukopenia  and  leukocytosis 
do  not  affect  the  stomach,  although  either  functional  or  or- 
ganic disease  of  the  stomach  may  result  from  the  same  cause 
which  produces  the  leukopenia  or  the  leukocytosis.  The 
symptomatic  gastric  hemorrhage  of  scorbutus  and  of  hemo- 
philia need  only  be  mentioned. 

The  diseases  of  the  red  corpuscles  are  responsible  for  the 
secondary  diseases  of  the  stomach  which  are  due  to  the  dis- 
eases of  the  blood.  But  not  all  the  gastric  troubles  which  are 
found  in  the  anemias  are  due  to  the  disease  of  the  blood.  The 
stomach  disease  and  the  blood  disease  may  be  accidental 
associations,  or  they  may  result  from  pathogenic  causes  which 
affect  both,  or  the  gastric  trouble  may  be  the  effect  of  the 
medication  employed  against  the  anemia,  as  the  iron,  arsenic, 
and  the  excitant  diet  which  it  is  the  rule  to  prescribe. 
Eliminating,  so  far  as  possible,  these  disturbing  factors,  our 
investigations  have  led  to  the  following  conclusions: 

Simple  oligochromemia  disturbs  neither  secretion  nor  the 
motor  function.  But  this  is  not  the  case  in  chlorosis.  In 
about  one-third  of  the  cases  of  true  chlorosis  the  stomach 
symptoms  predominate  in  the  clinical  history;  in  about  one- 
half  of  the  cases  there  are  gastric  symptoms  and  pain.  Vom- 
iting occurs  intermittently  in  about  ten  per  cent,  of  the  cases, 
and  loss  of  appetite  is  the  rule.  Disturbances  of  secretion  are 
more  frequent  than  would  be  indicated  by  the  complaints  of 
the  patients,  as  in  only  nine  per  cent,  of  the  cases  have  we 
found  secretion  normal  in  its  degree  and  in  its  evolution. 
Gastric  secretion  is  sometimes  normal  when  the  patient  com- 
plains of  digestive  trouble. 

As  regards  the  nature  of  the  stomach  trouble,  in  23  per 


THE  SECONDARY  DISEASES  OF  THE  STOMACH.       637 

cent,  of  the  cases  we  have  noted  a  diminution  of  secretion — 
in  some  cases  functional,  in  other  cases  due  to  gastritis.  But 
we  can  not  convince  ourselves  that  the  gastritis  is  due  to 
the  chlorosis  and  not  to  other  causes.  In  68  per  cent,  of  the 
cases  we  have  found  the  hydrochloric  acidity  excessive 
at  some  period  during  the  digestion  of  the  test-breakfast — 
excessive  free  HCl  at  the  expiration  of  one  hour  in  1 1  per 
cent,  of  the  cases,  excessive  physiological  HCl  (H  -f"  C)  in  32 
per  cent,  of  total  cases,  and  an  abnormality  in  the  evolution 
of  digestion  in  the  remainder  of  the  cases.  No  noteworthy 
myasthenia  existed  in  any  of  the  cases,  the  results  being 
obtained  by  using  the  ordinary  methods  and  by  controlling 
them  with  the  water-test  whenever  they  did  not  give  satisfac- 
tory results.  Briefly,  in  chlorosis  there  may  be  hyperesthesia 
gastrica,  or  there  may  be  adenohypersthenia  gastrica,  and  in 
some  cases  there  is  hypersthenic  gastritis.  Ulcer  was  present 
in  six  per  cent,  of  the  total  cases,  and  we  have  never  seen  a  gas- 
tric hemorrhage  in  pure  chlorosis  that  was  not  due  to  ulcer. 
Gastric  cramps  occur  in  chlorosis  when  it  is  accompanied  by 
gastroptosis  or  hyperchlorhydria.  Associated  with  the  gas- 
tric trouble  is  generally  found  neurasthenia  gastrica,  which 
is  as  it  should  be  when  the  influence  of  chronic  irritation  or 
irritable  weakness  of  the  abdominal  sympathetic  in  the  causa- 
tion of  chlorosis  is  held  in  mind. 

The  disturbing  influence  of  oligocythemia  on  the  stomach 
is  far  less  than  the  influence  of  chlorosis.  Hemorrhagic 
anemia  diminishes  secretion,  and  this  effect  is  often  seen  in 
ulcer  after  a  severe  hemorrhage.  But  the  normal  secretion 
or  the  hyperchlorhydria  returns  as  the  regeneration  of  the 
blood  advances.  In  grave  oligocythemia  secretion  may  be 
diminished,  and  the  gastric  glands,  like  the  noble  elements  of 
other  organs,  may  undergo  fatty  degeneration  and  atrophy. 
Ulcer  is  much  less  frequently  a  result  of  oligocythemia  than 
of  chlorosis.  In  the  study  of  the  effect  on  the  stomach  of 
oligocythemia,  be  it  dyshematopoietic,  degenerative,  or  hema- 
tocytolytic,  we  have  been  unable  to  discover  a  thread  to  guide 
us  in  the  confusion.  In  the  primary  cases  it  is  difficult  to 
eliminate  the  influence  of  medication  or  to  estimate  the  influ- 
ence of  the  causative  disease  in  the  secondary  cases,  as  in 
pyemia,  in  septicemia,  and  in  the  anemias  due  to  intestinal 
putrefaction  and  auto-intoxication.  In  a  majority  of  the 
simple  cases  of  mild  and  severe  oligocythemia  the  stomach  is 
normal. 


638  DISEASES  OF  THE  STOMACH. 

V.  DISEASES  OF  NUTRITION. 

The  various  diseases  of  nutrition  do  not  disturb  the  stomach 
to  an  equal  degree.  Chronic  rheumatism  produces  directly 
no  particular  disturbance.  Obesity  causes  little  more  than 
diminution  of  the  appetite,  the  gastric  disturbances  found  in 
this  disorder  of  nutrition  being  due  to  the  mode  of  life  and  to 
improper  treatment.  But  many  fat  people  are  active,  enjoy 
good  appetites,  and  have  excellent  digestion.  Fasting  pro- 
duces diminution  of  hydrochloric  acid  secretion  without 
diminishing  the  formation  of  the  ferments.  The  stomach 
ceases  to  act,  but  retains  its  functional  power.  In  chronic 
subnutrition  there  is  diminution  or  loss  of  HCl  secretion  with- 
out a  corresponding  diminution  of  the  ferments.  But  in  pro- 
longed subnutrition  of  a  severe  degree  secretion  is  not  simply 
in  abeyance,  but  it  may  be  permanently  impaired,  and  the 
weakness  of  the  stomach  muscle  is  in  keeping  with  the  weak- 
ness of  the  general  muscular  system.  We  would,  in  this 
connection,  emphasize  the  very  important  influence  of  emacia- 
tion and  loss  of  muscular  strength  in  the  causation  of  dis- 
placements of  the  abdominal  viscera — kidneys,  liver,  spleen, 
colon,  and  stomach. 

Diabetes,  be  it  constitutional  (nutritive),  nervous,  pancre- 
atic, alimentary,  or  hepatic,  may  disturb  the  stomach.  In 
many  cases  there  is  only  a  diminution  of  HCl  secretion. 
There  is  often  myasthenia  in  cases  of  long  standing,  which 
may  be  associated  with  hyperchlorhydria  or  with  hypo- 
chlorhydria,  but  which  is  most  likely  the  result  of  excessive 
eating  and  drinking  rather  than  of  the  diabetes.  It  is  the 
rule  to  find  no  serious  disturbance  of  the  stomach  in  diabetes, 
unless  there  be  great  emaciation,  advanced  cardioarterioscle- 
rosis,  or  nephritis.  But  it  should  be  remembered  that  the 
functions  of  the  stomach  may  be  insufficient,  and  under  such 
circumstances  the  diet  should  not  be  made  too  exclusively 
nitrogenous. 

The  gastric  troubles  of  gout  may  be  due  to  the  drugs  which 
are  commonly  employed,  to  the  restricted  diet,  to  the  second- 
ary nephritis  and  arteriosclerosis,  or,  finally,  to  the  disease 
of  which  the  uric  acid  precipitation  is  the  expression. 
There  may  be  an  associated  or,  sometimes,  a  secondary 
gastritis.  But  the  special  gastric  trouble  of  gout  is  myas- 
thenia, which  may  be  accompanied  either  by  hyperchlorhydria 
or  by  hypochlorhydria,  with  or  without  fermentation.  If 
there  be  hypochlorhydria  and  fermentation,  a  vicious  circle 
is  established,  for  this  secondary  gastric  trouble  of  gout  favors 


THE  SECONDARY  DISEASES   OE  THE   STOMACH.       639 

the  conversion  of  the  neutral  into  the  acid  phosphate  of  soda, 
and  may  cause  uric  acid  precipitation. 


VI.  DISEASES  OF  THE  KIDNEYS. 

It  is  difficult  to  study  the  effects  of  the  diseases  of  the  kid- 
neys on  the  stomach,  for  the  usual  medication  of  nephritis  is 
likely  to  do  the  stomach  injury,  and  the  two  organs  may 
become  diseased  from  the  same  causes.  But  excluding,  so  far 
as  possible,  these  sources  of  error,  it  may  be  stated  in  a  gen- 
eral way  that  the  stomach  troubles  of  nephritis  are  due  to 
acute  or  chronic  uremia.  The  retention  poisoning  may  act 
on  the  central  nervous  system  and  produce  vomiting,  which  is 
always  a  most  prominent  gastric  symptom  in  uremia,  whether 
gastritis  be  present  or  absent.  The  retention  poisoning  also 
leads  to  the  elimination  of  ammonia  compounds  by  the 
stomach,  and  the  HCl  may  be  neutralized,  so  that  the  analy- 
sis of  the  contents  gives  a  false  conception  of  the  activity  of 
secretion.  We  have  frequently  noticed  that  the  hypochlor- 
hydria  of  the  acute  exacerbations  of  chronic  nephritis  is 
replaced  by  normal  secretion,  or  even  by  hyperchlorhydria, 
during  the  period  of  quiescence  of  the  Bright's  disease  when 
renal  sufficiency  is  reestablished.  Indeed,  it  seems  that  it  is 
the  rule  in  the  early  period  of  chronic  nephritis  to  find  the 
gastric  irritation  displayed  by  hydrochloric  acid  in  excess. 
But  later,  the  hyperchlorhydria  is  replaced  by  permanent 
hypochlorhydria  symptomatic  of  chronic  gastritis.  The 
hydrochloric  acidity  diminishes  during  the  uremic  attacks, 
and  the  alkaline  or  nearly  neutral  vomit  may  contain  ammo- 
nia (white  cloud  produced  by  vapor  from  a  glass  rod  dipped 
in  HCl).  The  ferments  seem  to  be  destroyed  in  part,  or  are 
secreted  in  less  quantity  than  would  be  proportionate  to  the 
diminution  of  the  hydrochloric  acid  secretion.  Flatulency  is 
common,  although  fermentation  is  rare,  and  it  may  possibly 
be  due  to  the  decomposition  of  carbonate  of  ammonia.  The 
stomach  disturbance  is  a  rough  index  of  the  degree  of  renal 
insufficiency,  and  the  preservation  of  the  functions  of  the 
digestive  organs  protects  the  system  and  the  kidneys  against 
injury  by  gastro-intestinal  auto-intoxication. 

Stone  in  the  kidney  may  either  produce  no  gastric  trouble 
at  all  or  it  may  excite  reflex  vomiting.  We  have  sometimes 
found  hyperchlorhydria,  or,  more  frequently,  hypochlorhydria. 
The  painful  gastroduodenal  crises  of  movable  or  floating  kid- 
ney are   said   to   be  common,  but  the  disturbance  certainly 


640  DISEASES  OF  THE  STOMACH. 

originates  in  some  cases  in  the  cecum  and  colon,  and  in  others 
the  signs  and  symptoms  are  due  to  perinephritis. 


VII.  SPINAL   DISEASES. 

Myelitis,  multiple  sclerosis,  and  spinal  meningitis  may  be 
accompanied  by  reflex  vomiting,  by  h\-perciilorhydria,and  by 
painful  gastric  crises.  But  the  gastric  troubles  caused  in  this 
manner  are  either  so  rare  or  so  obviously  sympathetic  that  they 
hardly  deserve  mention.  It  is  not  so,  however,  with  the  gas- 
tric crises  of  locomotor  ataxia,  which  occur  during  the  course 
of  the  sclerosis  of  the  posterior  columns,  or  which  may  be 
the  first  revealing  sign  (in  about  five  per  cent,  of  cases)  of 
tabes  at  a  period  when  there  are  no  disturbances  of  the 
refle.xes,  of  sensation,  or  of  coordination. 

The  gastric  crises  begin  suddenly,  regardless  of  the  state  of 
repose  or  of  functional  activity  of  the  stomach,  and  regardless 
of  the  quantity  and  the  quality  of  the  diet.  There  may  be 
irregular  prodromal  symptoms — shooting  pains,  epigastric 
uneasiness,  depression  of  spirits,  and  restlessness.  The  crisis 
is  continuous,  and  is  manifested  by  pain,  by  vomiting,  and  by 
general  weakness  and  anxiety.  In  from  a  few  hours  to  several 
days  the  crisis  ends  as  suddenly  and  as  apparently  without 
cause  as  it  began. 

The  pain  is  not  always  present,  and  it  is  variable  in  quality 
and  intensity.  It  maybe  burning,  stabbing,  shooting,  cramp- 
like, moderately  severe,  or  almost  deadly  in  its  agony.  But  the 
pain  has  always  certain  distinctive  characteristics :  it  is  bilateral 
in  its  radiations;  it  is  not  relieved  by  vomiting,  by  alkalies,  or 
by  albuminous  food  ;  it  is  only  temporarily  diminished  by 
lavage,  and  then  only  in  the  beginning  of  the  crisis,  and  mor- 
phin  controls  it  only  during  the  period  of  narcotism.  Some- 
times, though  seldom,  the  pain  is  the  only  manifestation,  and 
it  may  then  be  cramp-like,  without  vomiting,  and  with  com- 
plete arrest  of  secretion.  Furthermore,  we  would  emphasize 
the  fact  that  the  quality  and  the  intensity  of  the  pain  bear  no 
relation  whatever  to  the  hydrochloric  acidity  of  the  contents 
of  the  stomach. 

Vomiting  maybe  absent,  but  usually  it  is  present,  obstinate, 
and  accompanied  by  nausea  and  by  retching.  It  may  be  the 
predominant  sj-mptom,  and  the  gastric  intolerance  may  be 
complete.  The  vomit  consists  of  whatever  may  be  in  the 
stomach  at  the  time — food,  gastric  juice,  mucus,  and,  event- 
ually, bile  and  pancreatic  juice.  The  crises  are  usually  ac- 
companied by  thirst  and  by  complete  loss  of  appetite. 


THE  SECONDARY  DISEASES  OF   THE  STOMACH.        64 1 

The  crises  are  not  always  of  the  same  severity,  and  conse- 
quently do  not  always  produce  the  same  effects  on  the  gen- 
eral system.  The  vomiting  and  pain  may  be  so  severe  that 
complete  collapse  is  produced  by  the  uncontrollable  vomiting 
and  the  intolerable  agony.  As  a  rule,  the  crises  become 
milder  as  the  spinal  disease  advances. 

The  crises  of  tabes  dorsalis  are  paroxysmal,  spasmodic,  and 
gastralgic.  The  nerves  and  the  muscle  of  the  stomach  are 
affected  to  a  much  greater  degree  than  is  secretion.  There 
is  pain,  loss  of  appetite,  and  cramps,  but  the  state  of  secretion 
is  determined  to  a  greater  extent  by  the  antecedent  state  of 
the  mucous  membrane  than  it  is  by  the  spinal  sclerosis.  If 
there  be  no  disease  of  the  mucous  membrane,  in  the  be- 
ginning of  the  crisis  there  is  hyperchlorhydria;  but  in  case 
the  crisis  is  prolonged  or  is  repeated  after  short  intervals, 
the  vomit  contains  less  and  less  HCl  and  ferments.  Under 
such  circumstances  gastric  secretion  is  normal  during  the 
intervals.  But  it  is  the  rule,  as  a  result  of  the  antisyphilitic 
or  antitabetic  medication,  to  find  chronic  asthenic  gastritis 
already  present.  The  quantity  of  hydrochloric  acid  in  the 
vomit  in  the  beginning  of  the  attack  displays  the  secretory 
power  of  the  diseased  mucous  membrane,  and  the  acid  is 
consequently  diminished.  During  the  course  of  the  attack 
the  acidity  becomes  less,  and  the  diminution  is  due  in  part 
to  the  reflux  of  the  duodenal  contents  into  the  stomach,  and 
to  the  capillary  hemorrhage  which  occurs  in  some  of  the  very 
severe  attacks.  There  seems  never  to  be  continuous  secre- 
tion, nor  is  there  myasthenia  with  retention  or  accumulation 
of  the  secretion  of  the  stomach.  Medication  has  no  appre- 
ciable effect  in  the  control  or  prevention  of  the  crisis.  It 
will  be  seen  at  a  glance  how  different  are  the  functional  signs 
of  the  gastric  crises  of  locomotor  ataxia  from  those  of  chronic 
hypersthenic  gastritis  or  from  the  paroxysmal  form  of  hyper- 
chylia  gastrica,  the  two  diseases  with  which  the  gastric  crises 
are  most  likely  to  be  confounded. 


VIII.  CEREBRAL  DISEASES. 

Meningitis, — particularly  basilar  meningitis, — cerebral  hem- 
orrhages, brain  abscess,  and  brain  tumor,  may  be  manifested 
by  vomiting.  The  vomiting,  which  has  the  peculiar  charac- 
teristics of  cerebral  vomiting,  is  central  and  symptomatic,  and 
can  not  be  properly  considered  a  secondary  affection  of  the 
stomach.  Cerebral  vomiting  is  easy,  projectile,  without  rela- 
41 


642  DISEASES  OF  THE  STOMACH. 

tion  to  meals  or  to  the  quality  of  the  diet,  is  not  accompanied 
by  disease  of  the  stomacli,  and  may  occur  in  crises.  In  every 
case  of  obstinate  vomitin<j  it  should  be  a  rule  to  look  for 
possible  cerebral  lesions  and  their  other  manifestations — 
vertigo,  headache,  motor  and  sensory  disturbances,  and 
changes  of  the  optic  disc  and  retina.  Brain  injury  has  been 
known  to  produce  capillary  gastric  hemorrhage.  Hyper- 
chlorhydria  is  more  frequent  in  melancholia,  in  dementia 
paralytica,  in  mania,  and  in  paranoia  than  is  normal  secretion, 
though  hypochlorhydria  is  also  found.  Cerebral  fatigue  may 
produce  paroxysmal  hyperchylia  gastrica,  but  the  most  com- 
mon gastric  affection  which  originates  in  the  central  nervous 
system  is  neurasthenia  gastrica. 

It  is  very  difficult  to  define  and  explain  the  gastric  troubles 
of  neurastlienia.  It  may  be  contended  that  the  disease  of 
the  stomach  is  only  an  accidental  association,  be  it  a  dynamic 
affection  or  an  anatomical  disease.  It  may  be  contended  that 
the  gastric  trouble  is  primary,  and  that  it  is  the  cause  of  the 
central  neurasthenia.  All  the  hypersthenic  diseases  of  the 
stomach  may  produce  general  neurasthenia,  and  in  latent 
forms  may,  during  a  variable  length  of  time,  be  manifested 
by  weakness  and  increased  irritability  of  the  central  nervous 
system,  even  without  subjective  gastric  symptoms.  It  may  be 
contended,  and  sometimes  with  truth,  that  the  central  neuras- 
thenia is  primary,  and  that  it  ma\'  produce  functional  disturb- 
ances of  the  stomach,  which  in  their  normal  evolution  may 
become  transformed  into  anatomical  diseases.  It  seems  wisest, 
in  the  prevailing  confusion,  to  avoid  partizan  theories.  If  we 
have  found  in  our  experience  tliat  about  one-third  of  the  cases 
of  central  neurasthenia  develop  secondary  affections  of  the 
stomach,  and  that  about  four-fifths  of  thecases  of  neurasthenia 
gastrica  (primary)  develop  some  of  the  signs  and  symptoms  of 
cerebral  and  spinal  neurasthenia,  the  observation  may  be  im- 
puted to  the  supposed  tendency  of  each  specialist  to  exaggerate 
the  importance  and  the  pathogenic  influence  of  the  organs 
whose  diseases  it  is  his  particular  business  to  treat.  This  per- 
sonal equation  may  be  ver\'  great,  and  we  admit  its  influence  ; 
but  we  should  be  more  inclined  to  accept  the  neurologist's 
opinion  if  it  were  more  frequently  the  custom  to  examine  the 
stomach  by  the  modern  methods.  In  our  experience,  the 
most  common  secondary  disease  of  the  stomach  in  cerebro- 
spinal neurasthenia  is  neurasthenia  gastrica.  There  may  be 
no  abnormality  of  secretion  or  of  the  motor  function — the 
patients  simply  suffer  and  complain,  and  are  overanxious  as  a 
result  of  the  sensations  which  accompany  digestive  activity, 


THE   SECONDARY  DISEASES  OF   THE  STOMACH.        643 

just  as  in  primary  neurasthenia  gastrica.  At  times  there  may 
be  hyperchlorhydria — free  HCl  may  appear  too  early  in  the 
course  of  the  digestion  of  the  test-breakfast,  or  it  may  be  too 
great  at  the  height  of  its  digestion,  or  the  appearance  of  free 
HCl  may  be  delayed  and,  eventually,  become  excessive  in 
quantity.  More  infrequently  there  may  be  hypochlorhydria. 
Or  there  may  be  myasthenia  with  a  mild  degree  of  stagnation, 
the  stomach  doing  its  motor  work  perfectly  for  a  certain 
period,  and  then  becoming  insufficient,  as  may  be  clearly 
shown  by  the  water-test.  But  the  functional  abnormality  is 
intermittent  and  inconstant,  for  if  the  central  neurasthenia  be 
accompanied  by  a  secretory  disorder  of  a  fixed  chemical  type, 
an  organic  change  in  the  mucous  membrane  is  present.  The 
anatomical  disease  may  bean  accidental  association,  or  it  may 
have  developed  in  consequence  of  the  predisposition  created 
by  the  neurasthenia  and  by  the  neurasthenic  functional  dis- 
order. 

The  secondary  affections  of  the  stomach  produced  by  hys- 
teria are  more  numerous  than  those  of  neurasthenia.  The 
most  important  are  anorexia,  hyperesthesia  gastrica,  anes- 
thesia gastrica,  and  hysterical  vomiting.  These  hysterical 
gastric  troubles  may  be  the  only  manifestations  of  the  hys- 
teria, or  the  psychosis  may  affect  some  of  the  voluntary  and 
conscious  functions  of  the  organism.  The  monosympto- 
matic  gastric  form  may  present  great  difficulty  in  diagnosis. 
Although  hysterical  stigmata  maybe  absent,  the  gastric  affec- 
tion may  possess  some  peculiar  and  suggestive  characteristic. 
The  anorexia  may  be  an  anorexia  with  a  fixed  idea  or  pur- 
pose. The  vomiting  is  always  alimentary  and  easy.  In 
spite  of  both  anorexia  and  vomiting,  nutrition  may  be 
perfectly  preserved  for  a  long  time,  and  there  is  no  organic 
disease  of  the  stomach  present  to  cause  them.  These  affec- 
tions begin  suddenly  and  without  an  apparent  cause,  and  end 
suddenly  and  in  an  inexplicable  manner.  They  have  no  rela- 
tion to  the  quality  or  quantity  of  the  diet,  and  often  run  their 
course  irregularly  and  in  a  manner  typical  of  no  particular 
disease  of  the  stomach,  and  in  total  disregard  of  all,  except 
suggestive  treatment.  These  and  many  other  well-known 
hysterical  characteristics  may  suggest  the  nature  of  the  puz- 
zling and  grotesque  affection. 

IX.  DISEASES  OF  THE  MOUTH,  NOSE,  AND  THROAT. 

It  is  exceedingly  difficult  to  determine  the  relation  of  the 
diseases  of  the  mouth,  nose,  and  throat  to  the  diseases  of  the 


644  DISEASES  OF  THE  STOMACH. 

stomach.  In  the  first  cliapter  of  the  Vicious  Circles  of  the 
Stomach  no  mention  was  made  of  the  possible  causation  of 
diseases  of  the  upper  air-passages  by  the  diseases  of  the 
stomach,  because  such  a  result  seems  to  be  very  infrequent. 
Acid  regurgitation  may  affect  the  throat  as  it  does  the  esoph- 
agus, and  tlie  diseases  of  the  stomach  may  influence  the  cir- 
culation, the  nutrition,  the  nervous  system,  etc.,  in  such  a  man- 
ner as  to  predispose  more  or  less  all  the  mucous  membranes 
of  the  body  to  inflammation.  That  is  about  as  much  as  can 
safely  be  said  without  danger  of  exaggeration.  The  auto- 
toxic  sore  throats  due  to  HjS  poisoning  are  of  intestinal 
origin. 

Diseases  of  the  mouth  may  disturb  gastric  digestion  by 
interfering  with  mastication  or  by  changing  the  reaction  and 
composition  of  the  mixed  secretion  of  the  mouth;  and  thrush 
may,  under  fit  circumstances,  extend  from  the  mouth  to  the 
stomach. 

It  is  often  contended  that  the  frequent  coexistence  of  nose 
and  throat  disease  with  gastric  disease  demonstrates  that  one 
or  the  other  disease  is  secondary.  But  the  two  may  be  pro- 
duced by  the  same  cause,  or  they  may  be  the  effects  of  differ- 
ent causes.  It  is  hard  to  find  a  perfectly  normal  nose  and 
throat  in  New  York,  but  diseases  of  the  stomach  are  by  no 
means  so  frequent,  and  in  fine  climates  and  in  better  hygienic 
surroundings  the  two  classes  of  diseases  are  far  less  frequently 
associated. 

Diseases  of  the  nose  and  throat  may  influence  the  stomach 
by  reflex  action,  by  local  irritation,  by  infection,  or,  in  some 
cases,  by  the  influence  on  the  general  health.  After  tabu- 
lating a  large  number  of  cases,  we  are  unable  to  detect  the 
reality  of  the  reflex  pathogenic  influence  on  the  stomach. 
There  is  no  disturbance  of  secretion  or  of  the  motor  function, 
which  appears  with  regularity  in  connection  with  diseases  of 
the  rhinopharynx.  The  swallowing  of  large  quantities  of 
mucopus  for  a  long  period  does  affect  the  stomach,  and  the 
pyogenic  cocci  may  grow  on  the  mucous  membrane  if  there  be 
but  little  HCl  secreted;  such,  anyway,  would  seem  to  be  the 
case,  as  we  have  seen  pyogenic  cocci  in  large  numbers  on 
little  pieces  of  the  mucous  membrane  found  in  the  expressed 
gastric  contents.  In  chronic  asthenic  gastritis,  associated 
with  purulent  rhinopharyngeal  diseases,  the  micro-organisms 
of  the  stomach  are  a  close  reproduction  of  the  micro-organ- 
isms which  are  swallowed.  The  tabulated  cases  show  another 
noteworthy  fact — the  diseases  of  the  stomach  which  are  most 
frequent  are  associated  with  the  most  frequent  diseases  of  the 


THE   SECONDARY  DISEASES  OF   THE  STOMACH.        645 

rhinopharynx.  While  the  etiological  relation  of  the  diseases 
of  the  stomach  and  the  diseases  of  the  throat,  nose,  and  its 
accessory  sinuses  is  still  an  open  question,  there  can  be  no 
doubt  that  it  should  be  the  rule  of  practice  to  treat  both  dis- 
eases simultaneously, 

X.  DISEASES  OF  THE  RESPIRATORY  ORGANS. 

Acute  pleurisy  produces  no  particular  disturbance  of  the 
stomach,  for  the  visceral  congestion  of  its  initial  period  is  but 
slight,  and  the  fever  does  not  run  high.  Large  effusions  may 
interfere  with  the  aeration  and  circulation  of  the  blood,  and 
with  the  movements  of  the  diaphragm,  which  facilitate  the 
circulation  in  the  abdomen  by  subjecting  the  organs  to  rhyth- 
mical compression.  But  gastric  digestion  proceeds  in  a  nor- 
mal manner  if  proper  attention  be  given  to  the  diet,  though 
reflex  vomiting  sometimes  occurs,  and  the  pleuritic  pain,  as 
does  all  severe  pain,  may  depress  the  functions  of  the  stomach. 
The  disturbance  of  gastric  digestion,  if  it  occurs,  passes  away 
in  a  short  time  without  doing  any  particular  damage.  Such 
is  not  the  case,  however,  with  empyema,  for  the  toxemia  de- 
presses secretion,  induces  myasthenia,  and  sometimes  leaves 
chronic  asthenic  gastritis  as  a  legacy. 

Acute  bronchitis  affects  the  stomach  to  a  greater  degree 
than  does  acute  pleurisy.  It  appears  that  acute  gastric 
catarrh  with  hyperchlorhydria,  which  is  the  common  disturb- 
ance of  the  stomach  in  acute  bronchitis,  is  only  an  associated 
disease  due  to  a  common  cause.  Chronic  bronchitis  and 
emphysema  produce  chronic  defective  aeration  of  the  blood 
and  dilatation  of  the  right  side  of  the  heart.  Passive  conges- 
tion and  catarrh  of  the  stomach  may  result,  and  the  swallow- 
ing of  the  expectoration  of  putrid  bronchitis  may  disturb 
secretion  and  irritate  the  mucous  membrane. 

Pneumonia  affects  the  stomach  very  seriously,  and  lobar 
pneumonia  is  more  active  in  this  respect  than  is  the  lobular 
form.  Obstinate  reflex  vomiting  may  occur  from  the  irritation 
of  the  pneumogastric  by  the  compression  of  the  consolidated 
lung,  and  it  often  follows  the  cough.  The  prolonged  chill, 
high  fever,  defective  aeration  of  the  blood,  and  the  insufficiency 
of  the  right  side  of  the  heart  produce  the  most  common  dis- 
ease of  the  stomach  in  pneumonia,  which  is  acute  gastritis. 
The  gastritis  may  develop  during  the  onset  of  the  pneumonia, 
but  it  often  appears  later,  when  the  heart  insufficiency  and 
cyanosis  are  most  marked.  The  initial  gastritis  is  accom- 
panied by  hyperchlorhydria    (vomit    of    17    cases),    but   the 


646  DISEASES  OF   THE   STOMACH. 

terminal  gastritis  is  accompanied  by  hypochlorhydria  (vomit 
of  three  cases)  or  by  absence  of  free  HCl  (vomit  of  eight 
cases).  Fortunately,  neither  pleurisy,  bronchitis,  nor  pneu- 
monia produce  myasthenia.  The  motor  function  remains 
unimpaired,  and  the  stomach  empties  itself  normally  through- 
out these  diseases,  unless  it  be  maltreated  or  already  diseased. 

Of  all  the  grave  organic  diseases,  pulmonary  tuberculosis 
exerts  the  greatest  influence  on  the  stomach,  and  thus 
weakens  or  destroys  the  system's  defense  against  the  progress 
of  the  disease.  If  nutrition  is  to  be  maintained  and  fortified, 
— and  all  agree  that  this  is  the  essential  basis  of  antitubercu- 
lar  medication, — the  integrity  of  digestion  must  be  preserved. 
If  the  drug  treatment  is  to  be  beneficial,  the  recuperative  and 
resisting  powers  of  the  body  must  be  increased.  As  soon  as 
the  functions  of  the  stomach  are  lost,  the  lungs  and  the  whole 
system  are  at  the  mercy  of  the  tuberculosis. 

Not  all  the  gastric  troubles  which  occur  in  the  course  of 
consumption  are  due  to  the  tuberculosis.  The  stomach  may 
be  already  diseased  when  the  tubercular  infection  begins,  and, 
indeed,  gastritis  (Hayem)  and  "  dilatation  "  (Bouchard)  create 
favorable  conditions  for  the  development  of  pulmonary  tuber- 
culosis. Consequently  the  gastric  trouble  may  be  primary 
and  not  secondary.  And,  again,  during  the  course  of  the 
tuberculosis  the  gastric  trouble  may  be  produced  by  ordinary 
causes,  and  not  only  in  spite  of,  but  sometimes  as  the  result 
of,  the  medication  adopted.  The  stomach  is  neglected  and 
injured  in  the  absorbing  effort  to  control  or  cure  the  pulmon- 
ary disease.  Or  the  stomach  may  be  affected  indirectly  by 
the  influence  of  the  pulmonary  tuberculosis  (mixed  infection) 
on  nutrition  and  on  the  blood.  But,  apart  from  all  these 
possibilities,  we  maintain  that  pulmonary  tuberculosis  fre- 
quently exerts  a  direct  and  injurious  influence  on  the  stomach. 

Our  conclusions  are  based  on  the  study  of  95  cases.  Of 
these, 47  were  first  seen  during  the  incipient  period,  26  during 
the  stage  of  consolidation,  and  12  during  the  period  of  cavity 
formation.  In  every  case  the  diagnosis  was  confirmed  by 
demonstrating  the  presence  of  the  tubercle  bacillus,  which 
was  not  found  in  seven  of  the  cases  of  incipient  tuberculosis 
until  several  weeks  after  the  patient  first  came  under  observa- 
tion, these  cases  beginning  clinical!)'  with  circumscribed  dry 
pleurisy  of  the  apex  of  the  lung. 

Of  the  47  cases  of  incipient  tuberculosis,  ten  manifested 
no  subjective  nor  objective  signs  of  an  anatomical  disease 
or  of  a  dynamic  affection  of  the  stomach.  Three  of  the 
remaining  cases  had  chronic  asthenic  gastritis;    there   were 


THE  SECONDARY  DISEASES  OF   THE   STOMACH.        647 

absence  of  free  HCl,  diminished  combined  HCl,  corre- 
sponding diminution  of  the  ferments,  excessive  quantity  of 
mucus,  and  no  (or  very  slight)  impairment  of  the  motor 
function.  Eighteen  other  cases  gave  only  traces  of  free 
HCl,  diminished  combined  HCl,  slight  diminution  of  fer- 
ments, with  mild  (13)  and  severe  (5)  forms  of  stagnation 
associated  with  more  or  less  active  fermentation.  It  is 
more  than  probable  that  the  gastric  trouble  in  these  18 
cases  antedated  the  tuberculosis,  but  the  motor  insufficiency 
was',  probably,  the  effect  of  the  tuberculosis,  as  primary  mild 
asthenic  gastritis  of  the  ordinary  type  is  characterized,  with 
but  i&w  exceptions,  by  preservation  of  the  motor  function. 
Retaining  the  myasthenia  as  the  only  tubercular  character- 
istic, these  18  cases  may  be  excluded,  along  with  the 
three  cases  of  chronic  asthenic  gastritis,  from  the  study  of 
the  gastric  troubles  of  the  incipient  period.  We  will  return 
later  to  the  discussion  of  the  evolution  of  these  cases,  eight 
of  which  complained  of  only  irregular  disturbance  of  the 
stomach  and  three  seemed  perfectly  satisfied  with  their  diges- 
tion. The  16  remaining  cases  of  this  group  will  now  be 
reviewed.  Three  of  them  suffered  from  the  digestive  form 
of  adenohypersthenia  gastrica ;  there  was  free  HCl  in  large 
excess,  diminished  or  normal  combined  HCl,  excess  of  fer- 
ments, no  excess  of  mucus,  and  a  perfectly  preserved  motor 
function.  Seven  other  cases  had  myasthenia  with  stagnation 
of  the  first  degree,  associated  with  secretory  irritation;  they 
showed  free  HCl  in  excess,  and  delayed  evacuation  of  the 
stomach.  One  of  these  patients  had  the  characteristic  pain 
and  tender  points  of  ulcer,  and  gave  the  history  of  hema- 
temesis,  there  being  no  blood  coloration  of  the  sputum  during 
the  following  day.  The  six  remaining  cases  gave  the  same 
functional  signs,  but  fermentation  was  also  present  in  all  of 
them,  and  in  two  of  the  cases  the  stomach  succeeded  in 
emptying  itself  only  during  the  night.  In  these  last  two 
cases  the  free  HCl  dropped  below  normal  after  the  stomach 
was  thoroughly  washed  out  and  a  proper  diet  had  been  given 
to  control  the  fermentation.  Briefly,  incipient  tuberculosis 
produces  simple  digestive  adenohypersthenia  gastrica  in  about 
six  per  cent,  of  the  cases,  and  myasthenia,  with  or  without 
fermentation,  leading  on  slowly  or  rapidly  to  gastritis,  in 
about  28  per  cent,  of  the  cases.  If  the  stomach  be  already 
diseased,  it  becomes  myasthenic. 

Of  the  26  cases  first  examined  during  the  stage  of  con- 
solidation, in  only  four  was  the  stomach  normal.  Five  were 
cases  of  chronic  asthenic  gastritis  with  severe  stagnation  (4), 


648  DISEASES  OF   THE   STOMACH. 

or  with  retention  (i),  and  with  no  free  HCl  (5).  It  was 
not  possible  to  determine  whetlier  the  gastritis  was  secondary 
to  the  tuberculosis  in  all  these  five  cases.  Of  the  remaining 
17  cases  of  this  group,  three  displayed  excessive  hydrochloric 
secretion,  13  variable  (sometimes  normal,  sometimes  excessive, 
sometimes  diminished)  HCl  secretion,  and  one  gave  only  a  trace 
of  free  HCl.  Of  all  17  cases,  myasthenia  with  fermentation 
was  present  in  the  mild  (5)  or  severe  (10)  stagnation  or  in  the 
retention  (2)  form.  Consequently,  during  the  stage  of  con- 
solidation there  may  be  myasthenia  with  secretory  irritation, 
or  there  may  be  gastritis  with  motor  insufficiency. 

All  the  12  cases  first  examined  during  the  stage  of  cavity 
formation  proved  to  be  cases  of  chronic  asthenic  gastritis 
with  motor  insufficiency.  In  four  of  these  there  was  gas- 
tric retention,  and  in  all  of  them  there  was  gastric  fermenta- 
tion. 

The  evolution  of  the  gastric  trouble  was  followed  closely 
in  some  of  these  cases.  By  lavage  and  diet  the  fermentation 
could  be  controlled  in  the  cases  with  cavities  or  softening, 
but  the  functions  of  the  stomach  were  not  perceptibly 
improved.  Little  more  could  be  done  than  adapt  the  diet  to 
the  obstinate  trouble.  Of  the  17  cases  in  the  consolidation 
group,  1 1  progressed  slowly  toward  complete  disappearance 
of  the  free  hydrochloric  acid,  and  the  motor  insufficiency 
increased  or  remained  stationary  for  a  short  time.  The  fermen- 
tation was  controllable,  but  the  functions  of  the  stomach 
could  not  be  improved.  The  results  of  the  treatment  of 
the  gastric  troubles  in  incipient  tuberculosis  were  more  en- 
couraging. Both  the  hyperchlorhydia  and  the  fermenta- 
tion in  all  16  cases  were  controlled  by  treatment.  The 
three  cases  of  adenohypersthenia  developed  myasthenia  as 
the  pulmonary  trouble  progressed,  and  the  one  which  lived 
longest  nearly  lost  the  free  HCl  before  death.  Of  the  remain- 
ing 13,  four  have  completely  recovered  their  gastric  func- 
tions, and  the  tubercular  process  is  stationary  ;  three  others 
developed  gastritis  before  death  ;  the  remaining  cases  were 
not  further  studied  by  the  modern  methods  of  examination. 
The  stomach  troubles  of  incipient  tuberculosis  are  sometimes 
curable,  and  by  proper  treatment  the  secretory  irritation  and 
the  fermentation  may  be  controlled.  The  development  of 
gastritis  may  be  postponed.  Myasthenia  is  the  most  obstinate 
and  the  most  characteristic  gastric  trouble  of  phthisis.  The 
gastritis  may  result  from  the  stagnation  and  secrctor}'  irrita- 
tion, and,  clinically,  may  manifest  itself  as  the  hypersthenic 
or  asthenic  form.     Round-cell  interglandular  and  subglandu- 


THE  SECONDARY  DISEASES   OF   THE  STOMACH.        649 

lar  infiltration  with  cloudy  swelling  and  degeneration  of  the 
secretory  cells  predominates,  either  ultimately  or  from  the 
beginning,  over  productive  glandular  inflammation  and  hyper- 
plasia.    The  gastritis  of  phthisis  is  a  mixed  gastritis. 

It  is  very  interesting  to  follow  the  evolution  of  the  14 
cases  the  functions  of  whose  stomachs  were  normal  when  the 
patients  first  came  under  observation,  ten  being  first  seen  dur- 
ing the  incipient  period  and  four  during  the  stage  of  consoli- 
dation. Four  of  the  ten  incipient  cases  complained  of  great 
malaise  and  gastric  discomfort  after  meals,  and,  beincr  anemic 
and  nervous,  were  probably  suffering  from  neurasthenia  gas- 
trica.  All  ten  cases  became  myasthenic  during  the  stage  of 
consolidation,  and  the  four  living  several  months  longer  de- 
veloped asthenic  gastritis.  The  others  died  without  further 
exploration  of  the  stomach,  having  been  taken  off  by  tuber- 
cular pneumonia.  Of  the  four  normal  cases  seen  during  the 
stage  of  consolidation,  one  had  suffered  from  reflex  vomiting, 
one  displayed  only  mild  myasthenia  two  months  before  death, 
and  the  vomit  of  another,  examined  during  his  last  days,  con- 
tained no  free  H  CI  two  hours  after  he  had  taken  a  glass  of  milk. 
But  the  pre-agonal  gastritis  should  be  excluded  from  the  study 
of  the  cases  of  gastritis  due  to  pulmonary  tuberculosis. 

But,  apart  from  these  gastric  troubles  of  phthisis, — adenohy- 
persthenia  gastrica,  myasthenia,  and  gastritis, — consumptive 
patients  sometimes  present  a  very  characteristic  form  of  vom- 
iting. The  vomiting  is  probably  reflex,  and  is  a  secondary 
dynamic  affection  of  the  stomach.  The  vomiting  is  alimentary, 
occurs  after  eating, — not  after  every  meal  (exceptions  few),  but 
chiefly  after  the  midday  or  the  evening  meal, —  begins  during 
or  after  coughing,  is  without  nausea,  is  performed  without 
effort,  and  ceases  without  leaving  much  discomfort.  This 
peculiar  form  of  vomiting  may  be  the  only  affection  of  the 
stomach  which  is  present  at  the  time,  or  it  may  be  associated 
with  the  adenohypersthenia  or  with  the  myasthenia  gastrica. 
It  was  noted  in  17  of  the  incipient  cases.  After  the  de- 
velopment of  gastritis  the  vomiting  changes  in  character, 
and  may  occur  without  preceding  cough,  either  after  eating 
or  when  the  stomach  should  be  empty,  and  is  accompanied 
by  nausea  and  retching.  If  retention  be  present,  it  may  be 
projectile,  copious,  and  recur  every  two  or  three  days,  the 
vomit  consisting  in  part  of  food  which  should  have  long  ago 
been  evacuated  into  the  duodenum.  It  is  easy  to  recognize 
the  reflex  vomiting  of  consumption,  and  its  presence  should 
always  direct  attention  to  the  lungs. 

The  fever  of  pulmonary  tuberculosis  is  without  much  influ- 


650  DISEASES  OF  THE  STOMACH. 

ence  on  gastric  secretion.  The  stomach  seems  to  become  ac- 
customed to  fever,  and  is  not  disturbed  by  the  high  tempera- 
ture, as  it  is  in  tlie  infectious  diseases.  The  control  of  the 
fever  by  antipyretics  does  not  improve  the  insufficiency  of 
secretion  in  puhnonary  tuberculosis.  However,  in  the  three 
cases  of  adenohypersthenia  gastrica,  excessive  acidity  dis- 
appeared when  the  temperature  became  persistently  high. 
When  the  hyperchlorhydria  depends  upon  the  local  irritation 
of  the  stagnant  contents  it  does  not  subside  as  the  fever  rises, 
nor  is  the  diminished  secretion,  due  to  asthenic  gastritis,  re- 
stored by  the  control  of  the  fever.  Indeed,  the  preservation 
of  the  appetite,  in  association  with  febrile  movements  and  a 
rapid  pulse,  should  direct  attention  to  the  lungs,  although  the 
patient  may  complain  only  of  the  stomach. 


NDEX. 


Abdomen,  appearance  of,  53 

inspection  of,  55 

palpation  of,  61,  62 

support  of,  573.    Se.&  Abdominal  belts. 
Abdominal  belts,  250 
in  gastroptosis,  573 
in  myasthenia  with  retention,  374 
in  vertical  displacement,  563 

coil,  236 

massage,  246,  247 

organs,  displacement  of,  566 

pain,  39 

tension,  58 
Abscess  in  purulent  gastritis,  387,  388 

metastatic.     See  Aletasiatic  abscess. 

subdiaphragmatic,  455.  Same  as  Abscess, 
subphrenic. 

subphrenic.    See  Subphrenic  abscess. 
Absorption,  140 

disorders  of,  216 

tests  of,  140,  141 
Abstinence  as  a  remedy,  186 
Acetate  of  iron  as  an  antidote  to  chromic 
acid,  395 

of   lead    in    hemorrhage    from    ulcer  of 
stomach,  504 
Acetic  acid,  153 

poisoning  by,  395 

fermentation,  153 
tests  of,  153 
Acetone  in  pyloric  obstruction,  596 

in  stomach,  611 
Acetonuria  in  cancer  of  stomach,  539 
Achylia,  18 

gastrica,  2S7,  438 

lactic  acid  in,  148 
Acid.      See    Acetic   acid;     Butyric   acid; 
Hydrochloric  acid;  Lactic  acid;  Uric 
acid. 

and  soda  method  of  inflation,  72-74 
Acidity  of  the  system,  620 
Acids  in  cardiospasm,  310 

in  gastroptosis,  567,  575 

poisonous,  action   of,     on   the   stomach, 
392 
Acne  in  myasthenia  with  retention,  366 

in  pyloric  obstruction,  592,  593 
Aconite  as  a  gastric  sedative,  255 

in  gastralgia,  280 

in  gastric  pain,  251 

in  gastrospasm,  315 
Acoria,  26S,  269 

treatment,  270 
Active  electrode,  241 
Acupuncture  in  subphrenic  abscess,  493 
Acute  gastritis,  378.    See  Gastritis. 

mycotic  gastritis,  382 

simple  gastritis,  378 

toxic  gastritis,  391 
Addison's  disease,  differentiation  of,  from 

cancer  of  stomach,  548 
Adelomorphous  cells,  84 


Adenasthenia  gastrica,  286,  301-303 
clinical  description,  301 
diet  in,  303 
differential  diagnosis,  302,  437 

from  catarrhal  gastritis,  409 
etiology,  301 
hydrochloric  acid  in,  301 
treatment  of,  245,  256,  302 
Adenocarcinoma  of  the  stomach,  517 
Adenohypersthenia  gastrica,  18,  31,  33,  34, 
286,  300.     See  hyperchlorhydria,  and 
Hyperchylia  gasti-ica. 
alkalies  in,  260 
bulimia  in,  266 
diet  in,  213 
differentiation  of,  from  gastralgia,  279 

from  ulcer  of  stomach,  478 
forms  of,  287 
gastrospasm  in,  314 
in  tuberculosis,  647 
milk  diet  in,  201 

physiological  treatment  of,  254,  255 
Adenoma  of  stomach,  544 
Adhesions  in  cancer  of  stomach,  519 

in  gastric  ulcer,  495,  506 
Aerophagia,  317 

nervosa,  318 
Air,  swallowing  of,  304.     See  Aerophagia. 
Albu  on  toxin  from  the   urine  of  tetany  pa- 
tient, 629 
Albumin,  calorimetric  and   nutritive  value 

,  '^^'  ^75 

dissimilation  of,  179 

products  of  digestion  of,  178 
Albuminous  food  in  catarrhal  gastritis,  412 
in  digestive  hyperchylia  gastrica,  297 
preparations,  195 
Albumins,  177-180 

dissolved,  in  rectal  feeding,  218 
Albuminuria  from  disease  of  stomach,  630 
Albumoses  in  myasthenia  gastrica,  215 

in  urine  of  cancer  of  stomach,  539 
Alcohol,  detection  of,  in  stomach-contents, 
154 

in  adenasthenia,  303 

in  catarrhal  gastritis,  411 

in  digestive  hyperchylia,  298 

in  disorders  of  absorption,  216 

in  gastroptosis,  574 

in  hyperchlorhydria,  294 

in  hyperesthesia,  212 

in  myasthenia  with  retention,  375 

in  myasthenia  with  stagnation,  361 

in  pyloric  obstruction,  605 

in  rectal  feeding,  218 

in  subacidity,  215 
Alcoholic  fermentation,  153 
Algesimeter,  Boas',  68 
Alimentary  principles,  combinations  of,  183 

tables  of,  184,  185 
Alizarin,  105 
Alkalies,  260 


651 


6s2 


INDEX. 


Alkalies  iti  Ueatinciil  of  ulcer  of  stomach, 

502,  50S 
Alkalinity  of  blood  in  cancer  of  stomach,  538 
Allorrhythmia  from  disease  of  stomach,  621 
Almond  milk,  217 

Animoiiionia>;ncsium  phosphate,  260 
Ammonium   chlorid    in     the  stomach-con- 
tents, 1 14 
Amphoric    breathing  in  diagnosis  of  sub- 
phrenic abscess,  494 
Anacidity,  301 

hydrochloric,  117 
Anaerobic  bacteria,  154 
Anatomical  diseases,  diet  in,  216,  217 
of  the  stomach,  3^8 

signs,  158-160 
Anderson,   McCall,   on   ulcer  of  stomach, 

443. 446 
Anemia    as   a  cause  of  stomach   disease, 
636 

gastric  hemorrhage  in,  15S 

in  cancer  of  stomach,  535 

in  diseases  of  the  stomach,  615,  616 

in  gastroptosis,  568 

in  glandular  atrophy,  435 

in  ulcer  of  stomach,  471-473 

in  vertical  displacement  of  stomach,  561 

vomiting  in,  327 
Anesthesia  gastrica  from  hysteria,  643 
Angular  form  of  vertical  displacement   of 

stomach,  559 
Anilin  sulphate.    See  Sulphate  of  aniliu. 
Annular  scirrhus,   differenliation  of,  from 

hypertrophy  of  pylorus,  545 
Anorexia  as  a  symptom,  45 

in  pyloric  obstruction,  590 

nervosa,  271-275 
clinical  description,  272 
diagnosis,  274 
differential  diagnosis,  274 
etiology,  271 
forced  feeding  in,  187 
from  hysteria,  643 
treatment,  274 
with  acoria,  269 
Antacids.  260 

Antenrieth  on  frequency  of  cancer  of  stom- 
ach, 512 
Anterior  axillary  line,  68 
Anti-albumose,  17S 
Antifebriii  in  hyperchylia,  300 
Antifermentative  drugs  in   myasthenic  re- 
tention, 376.     See  Antiseptics. 
Antimony,  poisoning  by,  397 
Antipeptone.  178,  293 
Antiperistalsis  from  intestinal  obstruction, 

632 
Antiphlogistic  effect  of  cold  water,  236 
Antipyrin  in  bulimia,  268 

in  gastric  pain,  251 

in  hyperchylia,  300 
Antisepsis,  chemical,  258,  259 
Antiseptics,  258,  259 
Antispasmodics   in  upward    displacement 

of  stomach,  557 
Apoplexy,  vomiting  in,  326 
Apparatus  of  Friedlieb,  233 

of  Hemmeter,  139 

of  Lcube-Rosenthal,  232 

of  Moritz,  157 

of  Soniervail,  232 

of  Soxhelet,  197 
Appendicitis    as 

abscess,  495 
Appetite,  44 

in  asthenia  gastrica,  301 

in  cancer  of  stomach,  523 

in  eructatio  nervosa,  319 


cause  of   subphrenic 


Appetite  in  gastritis  glandularis   prolifer- 
ans,  417,  418 

in  hyperchlorhydria,  2SS 

in  myasthenia  with  retention,  364 

in  paroxysmal  hyperchylia,  300 

in  pyloric  obstruction,  589,  590 

loss  of,  251,  27! -275 

from  disease  of  intestine,  632 
in  glandular  atrophy,  435 
Aromatic  sul])liates,  226 
Arrhythmia  from  disease  of  stomach,  621 

in  myasthenia  with  retention,  366 

in  neurasthenia  gastrica,  340 
Arseniate  of  soda  in  bulimia,  268 
Arsenic,  hromid  of,  in  bulimia,  268 

in  eructatio  nervosa,  320 

in  gastric  pain,  251 

in  neurasthenia  gastrica,  347 

in  obstruction  of  cardia,  583 

poisoning  by,  397 
Arteries,  diseases  of,  as  a  cause  of  stomach 

disease,  634 
Arteriosclerosis  as  a  cause  of  stomach  dis- 
ease, 304,  635 
Artificial  feeding,  187 
Asafetida  in  nervous  vomiting,  332 
Asepsis,  intragastric,  499 

in  treatment  of  ulcer  of  stomach,  499 
Asparaginic  acid  from  digestion  of  albumin, 

178 
Aspirator  of  Boas,  91,  92 
Assimilation,  definition  of,  171 
Asthenia  aft'ects  functions  of  stomach,  212 

gastrica,  electric  Ireaiinent,  242-246 
physiological  treatment,  256 
Asthenic     gastritis,    chronic,    18,    402-414. 

See  Gastritis  catarihalis  chronica. 
Asthma  dyspepticum,  305 
Atelectasis,  situation  of  stomach  in,  555 
Atresia  of  cardia,  congenital,  577 

of  pylorus,  congenital,  5S4,  587 
Atrophy  of  the  gastric  glands.    See  Gas- 
tritis glandularis  atrophicans. 
Atropin    in    cardiospasm,     307,  308.      See 
Belladonna. 

in  gastralgia,  280 

in  hyperchylia,  300 

in  pyloric  obstruction,  607 
Auscultation,  75-80 
Auscultatory  percussion,  72 
Autodigestion,  450,  451 
Auto-into.\icatioii,  47 

as  a  cause  of  neurasthenia  gastrica,  33S 

effect  of,  on  the  blood,  615 

gastric,  influence  of,  610 

in  gastric  tetanv,  62S 

in  intestinal  disease  from  disease  of  stom- 
ach, 613 

in  myasthenia  with  retention,  367 

in  pyloric  obstruction,  592 

intestinal,  633 

use  of  water  in,  227 
Autotoxic  sore  throat,  644 


Bacillus  acid i  lactici,  147 

butyricus,  152 

coli  communis,  155 

geniculatus,  144,  146.  147,  14S 

in  cancer  of  stomach,  514 
Backache  in  gastroptosis,  567 
Bacteria  of  the  stomach,  142-157 

putrefactive,  147 

zymogenic,  147 
Bacteriological  signs,  142-157 

treatment.  25S,  259 
Bacterium  coli  commune,  147 
Baked  apples,  211 


INDEX. 


653 


Balloon  sound,  Kulm's,  65,  66 
Bandage,  abdominal.  250 
Bardenhauer,  abdominal  bandage  of,  250 
Barlow   on    pneumolhorax    in   subphrenic 
abscess,  493 

on     subphrenic     abscess     in    ulcer     of 
stomach,  48S 
Basedow's  disease,  266 
Basilar  meningitis,  vomiting  in,  641 
Beaumont,  investigations  of,  iSS 
Bedsores  in  anorexia  nervosa,  273 
Beef  juice,  expressed,  196 
Beefsteak,  caloric  value  of,  196 

digestion  of,  193 
Belching,  esophageal,  317 

in  digestive  hyperchylia  gastrica,  295 

in  myasthenia  gastrica,  350 

in  neurasthenia  gastrica,  339 

nervous,  316-321 
Belladonna,  252.    See  Atropin. 

in  cancer  of  stomach,  551 

in  digestive  hyperchylia,  298 

in  eructatio  nervosa,  320 

in  gastralgia,  280 

in  gastroptosis  with  chronic  colitis,  575 

in  gastrospasm,  315 

in  hyperchlorhydria,  294 

in  hypersthenic  gastritis,  428 

in  nervous  vomiting,  332 

in  spasm  of  pylorus,  313 

in  ulcer  of  stomach,  503 
Belt,  Glenard's,  250 

Belts,  abdominal,  250.  See  Abdominal  belts. 
Bernay's  operation  in  pyloric  obstruction, 

608 
Berthold  on  ulcer  of  stomach,  443 
Bicarbonate  of  soda  as  an  antacid,  260 
in  hyperchlorhydria,  294 
in  myasthenia,  257 
in  stomach  inflation,  72 
in  ulcer  of  stomach,  502 
Bief  on  kefyr,  202 
Bile  in  digestion,  614 

in  the  stomach,  160 

in  vomit,  601 
Biliary  colic,  40 
Bilin   water   in   Carlsbad    cure   of   gastric 

ulcer,  507 
Bimuriare  of  quinin  in  gastralgia  nervosa, 

281 
Binaural  stethoscope,  72 
Biological  coefficient,  173 
Bircher,  operation  of,  377 
Bismuth  as  a  gastric  sedative,  255 

in  acid  poisoning,  396 

in  digestive  hypercliylia,  298 

in  hyperchlorhydria,  295 

in  mycotic  gastritis,  386 

in  pyloric  obstruction,  607 

subnitrate  as  a  corrective  of  magnesia, 
260 
in  ulcer  of  stomach,  503 
Biuret  reaction,  289 
Blister  in  nervous  vomiting,  332 
Blood,  alkalinity  of,  in  cancer  of  stomach, 
538 

corpuscles  in  cancer  of  stomach,  ,S37 

diseases  of,  as  a  cause  of  stomach  disease, 
636 

examination  of,  in  neurasthenia  gastrica, 
342 

in  anorexia,  273 

influence  of  disease  of  stomach  on,  615 
of  gastric  secretion  on,  615 

presence  of,  in  stomach,  158 

specific  gravity  of,  in  cancer  of  stomach, 
536 

tests  for,  158,  159 


Blue  litmus  pajier,  101 

Boas  and  Ewald,  test-breakfast  of,  95 

algesimeter  of,  68 

aspirator  of,  91,  92 

bandage  of,  250 

enema  of,  219 

method  of,  for  estimating  free  HCl,  106 
of  testing  for,  and  estimation  of,  lactic 
acid,  152 

on     lactic    fermentation     in     cancer    of 
stomach,  535 

on  the  location  of  cancer  of  stomach,  520 

reagent,  103 

stomach-tube,  64 

supper  in  myasthenia  gastrica,  354 
in  pyloric  obstruction,  593,596,604 

test  of,  for  labferment  and  labzymogen, 
121 
Boettcher  on  presence  of  bacteria  in  ulcer 

of  stomach,  449 
Bone-marrow,  210 
Border  cells  of  the  stomach,  83,  84 

in  the  secretion  of  HCl,  98 
Botkin  bottle,  157 
Bouchard,  nodosities  of,  367 

on   dilatation   favoring    development  of 
tuberculosis,  646 

on  enlargement  of  phalangeal  joints,  367 

on  subphrenic  abscess  in  ulcer  of  stom- 
ach, 488 

theory  of  auto-intoxication,  366 
Bourget  test-meal  of,  94 
Bouveret  method  of  stomach  inflation,  72 

on  eructatio  nervosa,  317 

on  toxins  from  gastric  contents,  628 
Bowel,  large,  function  of,  218 
Bradycardia  from  disease  of  stomach,  622 
Brain   injury  as   a  cause  of  gastric  hemor- 
rhage, 642 
Brandy  in  obstruction  of  cardia,  583 
Braun,  method  of,  no 
Brautigam  on  influence  of  sex  in  cancer  of 

stomach,  514 
Bread,  action  of,  on  stomach,  207 

action  of,  on  stomach  in  disease,  208 
Brinton    on    cancer  complicating  ulcer  of 
stomach,  485 

on   diagnosis   of  ulcer   of   stomach,  475, 
476 

on  hard  cancer  of  stomach,  516 

on  hematemesis   in   cancer   of  stomach, 

on  influence  of  sex  in  cancer  of  stomach, 

514 
on  mortality  in  ulcer  of  stomach,  497 
on  pain  in  ulcer  of  stomach,  461 
on     perforation     complicating    ulcer    of 

stomach,  486 
on  subphrenic  abscess  in  ulcer  of  stom- 
ach, 4S8 
on  ulcer  of  stomach,  446 
Brissaud  on  chlorate  of  soda  in  cancer  of 

stomach,  551 
Bromid  of  arsenic  in  bulimia,  268 
of  potassium  in  cardiospasm,  310 
of    sodium    in     neurasthenia     gastrica, 

347 
of  strontium  in  bulimia,  268 

in  gastric  pain,  252 

in  neurasthenia  gastrica,  347 
Bromids  in  cardiospasm,  307,  308 
in  eructatio  nervosa,  320 
in  gastrospasm,  315 
in  habitual  regurgitation,  322 
in  nervous  vomiting,  332 
Bronchitis  as  a  cause  of  stomach  disease, 

645 
in  myasthenia  with  retention,  366 


654 


INDEX. 


Briicke's  test  of  digestive  power  (pepsin), 

123 
Briiii  de  galop,  194 

ill  gastric  heart  disorders,  623 
in  iieurastlieiiia  gastrica,340 
Brush,  fa  radio,  246 

Bryant  on  death-rate  of  ulcer  of  stomach, 
445 
on  mortality  from  cancer  of  stomach,  513 
Bubbling   in  diagnosis   of   subphrenic   ab- 
scess, 494 
Bulimia,  266-269 
differential  diagnosis,  268 
etiology,  266 
pathology,  266 
treatment,  268 
Busch,  investigations  of,  188 
Butler  as  a  food,  210 
as  intesliiuil  diet,  217 
in  bulimia,  269 
in  cancer  of  slomacli,  553 
in  gaslroptosis  with  neurasthenia,  576 
in  hy|>erchU>rhydria,  294 
in  hypersthenic  gastrins,  427,  429 
in  neurasthenia  gastrica,  346 
in  obsiruciion  of  pylorus,  605,  607 
in  ulcer  of  stomach,  502 
Butyric  acid,  38,  152,  153 

eflfects  of  presence  of,  611 
fermentation,  1^2 
formalion  of,  200 
qualitative  test  for,  102 
fermentation  in  cancer  of  stomach,  533 
in  cardiospasm,  306 

in  diagnosis  between  benign  and  malig- 
nant pyloric  obstruction,  602 


Caffkin  in  paroxysmal  hyperchylia,  300 
Calcined  magnesia,  260 

in  hyperchlorliydria,  294 

in  ulcer  of  slomacli,  502,  505 

Calcuhis  as  a  cause  of  vomiting,  327 

Calf's  brain  in  catarrhal  gastritis,  412 

in  digestive  hyperchylia,  299 

foot  jelly,  217 

in  chronic  asthenic  gastritis,  412 
Calomel  in  gastric  fever,  391 

in  paroxysmal  hyperchylia,  300 
Calorimeiric  value  of  foods,  17.S,  176 
Calumha  In  adenasthenia,  303.  See  Cohnnbo. 
Camphorated   oil    and    ether    in    ulcer   of 
stomach,  503 
in  acid-poisoning,  396 
in  mycotic  gastritis,  386 
Cancer  of  cardia,  gastrostomy  in,  553 
of  stomach,  ,si2-5S4 
age  as  a  factor  in  diagnosis  of,  546 
anatomical  signs  of,  535 
appetite  in,  523 

as  a  cause  of  cardiac  stenosis,  577 
of  myasthenia,  3^9 
of  pyloric  incontinence,  333 
of  pyloric  obstruction,  585 
bacillus  geniculatus  in,  146 
bacteriological  signs  of,  533 
blr)od  changes  in,  535 

corpuscles  in,  537 
butyric  acid  in,  1.^3 
clinical  description  of,  520 
coma  in,  539 

complicating  ulcer  of  stomach,  485 
coiKlition  of  bowels  in,  539 
diagnosis,  540 

Irom  Addison's  disease,  548 
from  afleiiasthenia  gastrica,  302 
from     atrophy     of    gastric     glands, 
438 


Cancer  of  stomach,  diagnosis  of,  from  car- 
diospasm, 308 
from  chronic  asthenic   gastritis,  549 
from  chronic  hypersthenic  gastritis, 

423.  550 
from  malarial  cachexia.  549 
from  myasthenia  gastrica,  35S 
Irom  neurasthenia  gastrica,  344 
from  tuberculosis,  548,  549 
from  ulcer  of  stomach,  479 
diet  in,  552 

differential  diagnosis,  548 
edema  in,  529 
emaciation  in,  529 
etiology,  514 
fermentation  in,  533 
fever  in.  539 

formation  of  adhesions  in,  519 
frequency  of,  512 
functional  signs  of,  531 
functions  of  stomach  in,  543 
gastro-enlerostomy  in,  553 
hard, 516 
influence  of  age  upon,  513 

of  sex  upon,  514 
involving  body  of  the  organ,  522 
cardia, 521 
pylorus,  522 
lactic  acid  in,  4S1 
medical  treatment,  551 
medullary,  517 

method  of  dissemination  of,  519 
mortality  ofj  512 
motor  insufliciency  in,  519,  532 
nutrition  in,  530 
pain  in,  524 

pathological  anatomy,  515 
perforation  in,  520 
physical  signs,  525 
prognosis,  551 
pylorectomy  in,  553 
rest  in,  164,  551 

secretion  of  hydrochloric  acid  in,  531 
soft,  516 

spasm  of  pylorus  in,  311 
specific  gravity  of  blood  in,  ,'536 
surgical  lrealinent,553 
symptoms,  523 
treatment,  551 
tumor  in,  525-529 
urine  changes  in,  538 
vomiting  in,  524 
Cane-sug«r,  181 

Cannabis  indica  in  gastralgia,  280 
in  gastric  pain,  252 
in  gastrospasm,  315 
in  hyperchlorliydria,  294 
in  hypersthenic  gastritis,  429 
Canthos  plaster  in  nervous  vomiting,  332 
Capsule  electrode  of  Kinhorn,  239 
Carbohydrates,  181,  182 

digestion  of,  141 
Carbolic  acid  for  vomiting,  253 

in  gastric  pain,  2jS2 
Carbonateof  magnesia,  absorbability  of,  140 
Carbonic  acid  water  as  a  stomach  douche, 

256 
Carcinoma    of  stomach.      See    Cancer  of 

stomach. 
Cardia,  52 
obstruction  of."  See  Obstruction  0/ cardia. 
spasm  of,  304-311 
Cardiac  orifice  of  stomach,  51 
Cardialgia,  hot  compress  in,  235 
Cardioresi>iratory  symptoms  in  pyloric  ob- 
struction, 593 
Cardiosclerosis  as  a  cause  of  stomach  dis- 
ease, 635 


INDEX. 


655 


Cardiospasm,  304 

diet  in,  310 

differential  diagnosis,  308 

treatment,  310 

use  of  sound  in,  307 
Cardiovascular  paroxysms  from  disease  of 

stomach,  623 
Carlsbad  and  rest  cure  in  gastric  ulcer,  506 

cure  in  ulcer  of  stomach,  503 

sails  in  gastric  ulcer,  507 

in  gastroptosis  with  chronic  colitis,  575 

water  in  hypersthenic  gastritis,  427 
Carminatives   in   upward  displacement   of 

stomach,  557 
Cascara  in  gastroptosis  with  chronic  colitis, 

^575.      ^. 

Casern,  digestion  of,  199 

Cassy   on   subphrenic  abscess   in   ulcer   of 

stomach,  488 
Catarrh  of  stomach  from  bronchitis,  645 
Catarrhal  gastritis,  405 
icterus,  influence  of,  on  disease  of  stom- 
ach, 633 
Caustic  alkalies,  poisoning  by,  396 
Cecum,  emptying  of,  by  massage,  249 
Celestins  vichy  in  ulcerof    stomach,  503 
Cell,  function  of,  in  nutrition,  170,  171 
Cells  of  the  nervous  system,  264,  265 
Cellular  activity  in  heat  production,  174 

theory  of  nutrition,  168 
Cellulomuscular  hypertrophy  as  a  cause  of 

obstruction  of  pylorus,  585 
Central  vomiting,  326 
Cereals,  207 
as  intestinal  diet,  217 
in  adenastheni,a,  303 
in  digestive  hyperchylia,  299 
in  gastritis  glandularis  atrophicans,  441 
in  gastro-intestinal  fermentation,  209 
in  gastroptosis,  574 

with  neurasthenia,  576 
in  gastrospasm,  315 
in  hyperchlorhydria,  294 
in  hypersthenic  gastritis,  427 
in  myasthenia  with  retention,  375 

with  stagnation,  361 
in  neurasthenia  gastrica,  346 
in  obstruction  ot  pylorus,  605 
in  ulcer  of  stomach,  502 
Cerebral  diseases  as  causes  of  stomach  dis- 
ease, 641 
fatigue,  165 
a  cause  of  hyperchylia  gastrica,  642 
in  hyperchlorhydria,  287 
tumors,  vomiting  in,  326 
vomiting,  641 
Cerebrospinal  neurasthenia  as  a  cause  of 

neurasthenia  gastrica.  642 
Cerium  oxalate  in  vomiting,  253,  332 
Cervico-esophageal  galvanization,  310 
Cervicogastric  galvanization,  243 
in  nervous  vomiting,  332 
in  regurgitation,  322 
in  spasm  of  the  pylorus,  313 
Chalk  as  an  antidote,  396 

prepared,  in  ulcer  of  stomach,  502 
Champagne  in  mycotic  gastritis,  3S6 

for  vomiting,  253 
Cheese  in  pyloric  obstruction,  607 
Chemical  antisepsis,  25S,  259 

methods  of  quantitative  analysis,  110 
treatment,  259-261 
Chewing  the  cud,  322-325 
Chibret  on  action  of  milk,  198 
Chicken  in  catarrhal  gastritis,  412 
in  digestive  hvperchylia,  299 
in  hvpersthenic  gastritis,  426 
in  obstruction  of  pylorus,  605 


Chicken  in  ulcer  of  stomach,  507 

Chief  cells,  83,  84 

Chloral  hydrate  in  eructatio  nervosa,  321 

in  nervous  vomiting,  332 

in  spasm  of  the  pylorus,  313 
Chlorate    of  soda   in   cancer  of  stomach, 

551 
Cblorid  of  calcium  in  adenasthenia,  303 

of  iron  as  a  test  for  mucus,  129 
Chloroform  in  nervous  vomiting,  332 

in  vomiting,  327 

water,  280 
Chlorometric  analysis,  105 
Chlorosis  as   a  cause   of  stomach  disease, 

636  . 

Chocolate  in  myasthenia  with  stagnation, 

361 

in  obstruction  of  cardia,  583 
Cholangitis  as  a  cause  of  stomach  disease, 

633         .     . 
Cholelithiasis   as  a  cause  of  stomach  dis- 
ease, 634 
as  a  cause  of  vomiting,  327 
differentiation   of,    from   gastralgia   ner- 
vosa, 279 
hyperchlorhydria  in,  2S7 
Chomel,  method  of,  for  testing  motor  func- 
tion of  stomach,  135 
on  digestion,  163 
Chromic  acid,  poisoning  by,  395 
Chronic  asthenic  gastritis.     See    Gastritis 
catarrhalis  chronica. 
atrophic   gastritis.     See    Gastritis  glan- 
dularis atrophicans. 
gastritis,  398 

hypersthenic  gastritis,  414.    See  Gastritis 
glandularis  proliferans. 
Chvostek  on  duodenal  ulcer,  484 
Chvostek's  sign,  627 
Cider  in  adenasthenia,  303 
Cinchona  in  adenasthenia,  303 
in  gastroptosis,  574 

with  chronic  colitis,  575 
Circulation,  influence  ot  disease  of  stom- 
ach on, 621 
Cirrhosis,   hypertrophic,   influence    of.   on 

stomach  disease,  634 
Classification  of  stomach  diseases,  18-20 
Climate  in  treatment  of  neurasthenia  gas- 
trica, 345 
Clinical  history,  25-47 

Clothing,  arrangement  of,  in  treating  gas- 
troptosis, 572 
Coal-tar  analgesics  in  gastric  pain,  251 
Coca  as  gastric  sedative,  255 
extract  of,  269 
in  cardiospasm,  310 
in  gastric  pain,  252 
in  nervous  vomiting,  332 
in  spasm  of  the  pylorus,  313 
Cocain  for  vomiting,  253 
Cocci  of  the  stomach,  144,  145 
Cocoa  in  gastritis  glandularis  atrophicans, 
442 
in  hyperchlorhydria,  294 
in  myasthenia  with  stagnation,  361 
in  obstruction  of  cardia,  583 
in  obstruction  of  ))ylorus,  605 
Codein  in  bulimia,  268 
in  cancer  of  stomach,  551 
in  gastralgia,  280 
in  gastric  pain,  252 
in  gastrospasm,  315 
in  hyv>erchlorhydria,  294 
in  hypersthenic  gastritis,  429 
in  obstruction  of  cardia,  583 
in  pyloric  obstruction,  607 
in  ulcer  of  stomach,  505 


656 


INDEX. 


Codein  phosphate,  252 

ill  mycolic  gastritis,  386 

in  iiervuus  vomiting,  332 

in  spasm  of  the  pylorus.  313 
Cod-liver  oil.  210 

in  cancer  of  stomach,  553 

ill    gastritis    glandularis    atrophicans, 

4^2 

in  gastroptosis  with  neurasthenia,  576 
Coefticient,  biological,  173 
Coffee  in  adeiiaslhc-nia,  303 
ill  digestive  h\  perchylia,  298 
in  gastric  sensibility,  213 
in  gastritis  glandularis   atrophicans,  442 
ill  liyperchlorhydria,  294 
ill  myasthenia  with  stagnation,  361 
in  obstruction  of  pylorus,  605 
ill  subacidity,  215 
Coffee-grounds  vomit,  466,  480 

ill  cancer  of  stomach,  525 
Colalgia  in  intestinal  myasthenia,  351 
Cold  compress,  236 
rater,  action  1 
douche,  235 


,23. 
of. 


water,  action  of,  on  stomach,  227,  228 


sedative  effect  of,  236 
Colic,  gall-stone,  278 

intestinal,  279 
Colitis  associated  with    neurasthenia  gas- 

trica,  342 
Collapse  in  gastric  ulcer,  treatment  of,  505 
Colloid  metamorphosis  of   soft  cancer  of 

stomach,  518 
Colon,  tumors  of,  543 

Color  methods  of  quantitative  acid-analy- 
sis, 105-110 
Coloration-tilratioii.  105 
Colunibo  ill  anorexia  nervosa,  275 

in  asthenia  gastrica.  256 
Coma  in  cancer  of  stomach.  539 
Combination  color  method.  107 
Combined  hydrochloric  acid.  101 
Compensation  In  glandular  atrophy,  434 

in  pyloric  obstruction,  586 
Compress.  235.  236 

Priessiiitz.236.     See  Prifssnitz  compress. 
Cotipression  myelitis,  vomiting  in,  326 
Comte  on  gastro-enterostomy,  510 

on   operations   for    perforating    ulcer  of 
stomach.  510 

on  perforation  in  ulcer  of  stomach,  486 
Condinieiits  in  cardiospasm.  310 

in  digestive  hyperchylia.  298 

ill  gastric  sensibility,  212 

in  liyperchlorhydria.  287.  294 

ill  invasthenia  with  stagnation,  336 

in  subacidity,  215 

in  nicer  of  stomach,  502 
Condurango  in  asthenia  gastrica,  256 

in  cancer  of  stomach,  551 

in  neurasthenia  gastrica,  347 
Congenital  atresia  of  cardia,  577 

stenosis  of  pylorus,  587 
Congo-red  as  a  test  for  HCI,  102 
Constipation  in  anorexia.  273 

ill  cancer  of  stomach,  539 

in  hyperchlorhydria,  290 

in  myasthenia  with  stagnation,  351,  363 

in  neurasthenia  gastrica.  347 

in  periodical  vomiting.  329 

in  pyloric  obstruction.  588.  589 

in  ulcer  of  stomach,  474 

treatment  of,  502 
Coniiimiition  as  a  cause  of  stomach  disease, 

646 
Continuous  secretion,  285 

ill  myasthenia  with  retention,  371 
Contraindications  to  the  use  of  the  stomach- 
tube,  89 


Convulsions  from  disease  of  stomach,  629 
in  myasthenia  with  retention,  366 

Corn  bread  in  pyloric  obstruction,  607 

Cornmeal,  2C9 
in  p>  loric  obstruction,  607 

Corset,  abdominal,  of  Landau,  250 
as  a  cause  of  vertical   displacement  of 

stomach.  557,  558 
-stomach.  566 

Cramps  in  pyloric  obstruction,  592 

Cream  as  intestinal  diet,  217 
in  digestive  hyperchylia,  299 
in  hyperchlorhydria,  294 
in  obstruction  of  pylorus,  605,  607 

Creosote  as  a  gastric  antiseptic,  25H 

Cruveilhieroii  pain  in  ulcer  of  stomach,  461 

Cseri  method  of  expressing  stomach-con- 
tents, 248 

Cud-chewing.  322-325 

Cullingsworth  on  infantile  cancer  of  stom- 
ach, 513 

Culture  soil,  change  of,  259 

Current,  density  of,  241 
I    Custard  in  pyloric  obstruction.  607 
i    Cyanid  of  iron,  113 
I    Cynorexia,  266-269 

Czeriiy  on  pylorectomv  in  cancer  of  stom- 
I       ach,  554 


Dahlaup  on  ulcer  of  stomach,  443 
Debove  meat  powder  in  gastric  ulcer,  508 
Debove's  neutralization  method  of  treating 

gastric  ulcer,  508 
Decinormal  acid  silver  nitrate  solution,  112 

solution  of  sulphocyanid  of  ammonium, 
H3 
Deformity  as  a  sequel  of  ulcer  of  stomach, 

4q6 
Deglutition  sounds  and  noises,  75 
Dehio  method  for  estimating  elasticity  of 
stomach,  70,  138 
in  myasthenia  gastrica,  353 
Delayed  evacuation  of  stomach,  140 
Delomorphous  cells,  84 
Descent  of  the  stomach,  total,  564 
D'Espiiie    on    mortality    from     cancer    of 

stomach.  513 
Devic  extract  from  stomach-contents,  628 
Dextrinized  bread,  216 
De  Yong,  method  of  testing  for  lactic  acid, 

Diabetes,  acoria  in,  269 

as  a  cause  of  stomach  disease,  638 
Diagnosis  and  diagnostic  methods,  21 
Diaphragm,  movements  of,   in  subphrenic 

abscess,  493 
Diaphragmatitis  in  subphrenic  abscess  from 

ulcer  of  stomach,  492 
Diarrhea  in  anorexia,  273 

in  cancer  of  stomach.  539 

in  chronic  atrophic  gastritis,  435 

in  ulcer  of  stomach,  treatment  of,  502 
Diet,  165-226 

correctness  or  incorrectness  of,  223 

general  rules  for  selection  of,  168 

in  adenasthenia,  303 

in  cancer  of  stomach,  552 

in  cardiospasm,  310 

in  catarrhal  gastritis.  411 

in  gastritis  glandularis  atrophicans,  441 

in  gastroptosis.  574 
with  chronic  colitis.  575 

in  gastrospasm,  315 

in  hyperchlorhydria,  293 

in  hypersthenic  gastritis,  426 

in  myasthenia  with  stagnation,  360 

in  neurasthenia  gastrica.  345.  346 


INDEX. 


657 


Diet  in  obstruction  of  cardia,  583 
of  pylorus,  604 
in  regurgitation,  322 
in  retention  myasthenia,  374 
in  spasm  of  pylorus,  313 
in  ulcer  of  stomach,  500 
in  upward  displacement  of  stomach,  557 
insufficient,  172 
prescription  of,  223 

selection  of,  in  disease  of  stomach,  167 
Digestibility    of  food,   clinical    conception 
of,  191 
Penzoldt's  table  of,  190 
Digestion  in  neurasthenia  gastrica,  337 
of  beefsteak,  193 
of  bread,  193 
of  carbohydrates,  141 
of  meat,  193 
of  milk,  193 
of  proteids,  142 
of  roast  beef,  193 
of  test-meals,  95-97 
Digestive  hygiene,  162-165 
hyperchylia  gastrica,  295-299 
mixtures,  260 
superacidity  in   ulcer   and    neurasthenia 

gastrica,  343 
symptoms,  36 
.  tube,  48 

work,  141 
Digitalis  in  upward  displacements  of  stom- 
ach, 557 
Dilatation  of  stomach,  18,  19 

of  stricture  of  cardia,  583 
Dimethylamidoazobenzol,  103,  106,  107 
Diphtheria  as    cause  of   myasthenia    gas- 
trica, 348 
Diphtheric  gastritis,  387 
Diplopia  in  pyloric  obstruction,  592 
Dirt-eaters,  271 

-eating,  271 
Diseases  of  arteries  as  causes  of  stomach 
disease,  634 
of  blood  as  causes  of  stomach  disease,  636 
of  brain  as  causes  of  stomach  disease,  641 
of  heart  as  causes  of  stomach  disease,  634 
of  intestines  as  causes  of   stomacli  dis- 
ease, 632 
of  kidneys  as  causes  of  stomach  disease, 

639 
of  liver  as  causes  of  stomach  disease,  633 
of  mouth,  nose,  and  throat  as  causes  of 

stomacli  disease,  643 
of   nutrition    as  causes   of  stomach  dis- 
ease, 63S 
of  respiratory  organs  as  causes  of  stom- 
ach disease,  645 
of  spine  as  causes  of  stomach  disease,  640 
of  stomach,  effects  of,  610 
from  disease  of  intestine,  632 
influence  of,  on  blood,  615 
on  heart  and  circulation,  621 
on  intestine,  611 
on  kidneys,  630 
on  liver,  614 
on  nervous  system,  624 
on  nutrition,  617 
on  skin,  62S 
secondary,  631 
Displacement  of  stomach,  downward.    See 
Gastroptosis. 
lateral.  See  Displacentcnl  of  stomach, 

vertical. 
upward,  555 

clinical  description,  555 
etiology,  555 
objective  signs,  556 
treatment,  556 

42 


Displacement   of  stomach,  vertical,  557 
angular  form,  559 
clinical  description,  560 
etiology,  557 
fish-hook  variety,  559 
genesis,  558 
objective  signs,  561 
pathological  anatomy,  558 
prognosis,  563 
straight  form,  560 
treatment,  563 
Displacements  of  stomach,  19,  554-576 
Dispora  caucasica,  202 

Dissolved  albumins  in  rectal  feeding,  218 
Donkin  on  treatment  of  gastric  ulcer,  50S 
Dorsal  tender   point  in  ulcer  of  stomach, 

469 
Dorsogastric  galvanization,  302 
Douche,  intragastric,  234 

Scottish,  303 
Doyen  on  gastro-enterostomy,  509 
Dragging  sensations  in  gastroptosis,  567 
Drinking  water,  action  of,  on  stomach,  227 
Duck  as  a  food,  195 
Dulness    on   percussion   in  obstruction  of 

cardia,  5S0 
Dunbar  tube,  157 

Duodenal  obstruction  as  a  cause  of  gastric 
retention,  635 
differentiation  of,  from  pyloric  obstruc- 
tion, 600 
orifice  of  stomach,  51 
tenderness,  67 
ulcer,  487 
in  differentiation   between  pyloric  and 
duodenal  obstruction,  601 
Duodenohepatic    ligament,  elongation    of, 

560 
Duodenostomy   in  pyloric  obstruction,  608 
Dynamic  affections,  motor,  304 
of  secretion,  285 
of  stomach,  260 
meats  in,  194 
sensory,  266 
Dyscrasia,  fibroid,  565 
Dyshematopoiesisfrom  disease  of  stomach, 

615 
Dyshematopoietic  oligocythemia  from  sub- 
nutrition,  615 
Dyspepsia  of  liquids,  215,  355 
Dyspeptic,  the,  26 
Dysphagia,  37 
in  cardiospasm,  305 
in  obstruction  of  cardia,  578 
Dyspnea  in  spasm  of  cardia,  305 


EcHiNOCocci   as  a    cause    of    subphrenic 

abscess,  495 
Eczema  from  disease  of  stomach,  630 

in  myasthenia  with  retention,  366 

seborrhceicum  from  disease  of  stomach, 
630 
Edema  in  cancer  of  stomach,  529 
Edinger  sponge-method,  86 
Egg,  206 

caloric  value  of,  196 

hard-boiled,  207 

in  cancer  of  stomach,  553 

in  digestive  hyperchylia,  299 

in  gastritis  glandularis  atrophicans,  441 

in  gastroptosis,  574 
with  chronic  colitis,  375 
with  neurasthenia,  576 

in  hyperchlorhydria,  294 

in  myasthenia  with  retention,  375 
with  stagnation,  361 

in  obstruction  of  cardia,  583 


658 


INDEX. 


Egg  in  pyloric  obstruction,  607 

in  ulcer  of  stomach,  502 

poached, 207 

sofl-boiled,  207 

wliite  of,  206 
Einhorn,  tapsule  electrode  of,  239 

gastrograph  of.  139 

intragastric  spray,  235 

method  of  illuminating  stomach,  58 

stomach-bucket,  85 
Elastic  belts  in  gastroptosis,  573 
Elasticity  of  stomach,  estimation  of,  138 
Electric   ilhiminalion   of  the   stomach,  58- 
60 

lamp,  ^S,  59 
Electricity,    contraindications    to    use    of, 
240-242 

duration  of  application  of,  241,  242 

in  adenasthenia  gastrica,  245,  302 

in  asthenia  gastrica,  242 

in  bulimia,  268 

in  chronic  gastritis,  245 

in  digestive  hyperchylia,  298 

in  eructatio  nervosa,  320 

in  gastric  hemorrhage,  241 

in  gastroptosis,  574 
with  neurasthenia,  576 

in  gastrospasm,  245 

in  hyperchlorhydria,  290,  293 

in  hypersthenia  gastrica,  245 

in  myasthenia  gastrica,  244' 
with  retention,  374 
with  stagnation,  363 

in  nervous  vomiting,  331 

in  neurasthenia  gastrica,  242 

in  rumination,  325 

uses  of,  238-246 
Electrization,  intragastric,  244 
Electrode,  "  active,"  241 

Eiiihorn's  capsule,  239 

nickel-plated,  241 

of  Rosenheim,  244 

plate.  243-245 

roller,  243 

Rosenheim's  intragastric,  238 

Wegele's  spiral,  238,  239 
Elimination,  definition  of.  171 
Emaciation.    See  Inanition  ^n<\  Syniplonia- 
tology. 

as  a  symptom,  46 

in  carcinoma,  527,  530 

in  chronic  hypersthenic  gastritis,  419 

in  gastroptosis.  567 

in  hyperchylia  gastrica,  296 

in  myasthenia  with  retention,  365 

in  neurasthenia  gastrica,  338 

in  obstruction  of  cardia,  579 
of  pylorns,  587 

in  subphrenic  abscess,  493 
Embolism,  vomiting  in,  326 
Emphysema  as  a  cause  of  stomach  disease, 

645 
Empyema  as  a  cause  of  stomach  disease, 
64=, 
in  ulcer  of  stomach,  493 
Emulsiouized  fats  in  rectal  feeding,  218 
Enema,  nutritive,  218 

in  obstruction  of  cardia,  583 
of  Boas,  219 
of  Ewald,  219 
of  Leube,  219 
Energy,  potential,  of  the  body,  173 
Engrafted  cancer,  485 

Enteritis    membranacea    associated    with 
neurasthenia  gastrica,  342 
from  disease  of  stomach,  613 
in  gastroptosis,  567 
Hnteroptosis  as  a  cause  of  gastroptosis,  633 


Enteroptosis  caused  bv  gastroptosis,  61^, 

633 
Environment  as  affecting  the  stomach,  162 
Epigastric  pain,  2S0 

in  hyperchlorhydria,  291 

tender  point  in  ulcer  of  stomach,  469 

tenderness,  67 
Erb    on    galvanic    excitability  in    gastric 

tetany,  627 
Erb's  sign.  627 
Ergot  in  digestive  hyperchylia,  29S 

in  gastroptosis,  574 

in  hemorrhage  from  ulcer  of  stomach,  505 

in  hypersthenic  gastritis,  428 

in  myasthenia  with  stagnation,  363 
Eructatio  nervosa.  316-321 
diagnosis,  320 
etiology,  319 
treatment,  320 
Eructation,  316-321 
Erythema  in  myasthenia  with  retention,  366 

fugax  in  pyloric  obstruction,  593 
Erythrodextrin,  181 
Esojihageal  belching,  317 

hemorrhage,  differentiation  from  gastric 
hemorrhage  in  ulcer  of  stomach,  468 

orifice  of  stomach,  51 

regurgitation.  322 

stagnation  in  obstruction  of  cardia,  578 

veins,  varicose.  309 
I        vomiting  in  obstruction  of  cardia,  580 
Esophagismus,  304.  577 
Esophagus,  sacculation  of,  309 

sounding  of,  in  obstruction  of  cardia,  580 
Ether  in  vomiting,  327 

spray  in  nervous  vomiting,  332 
Ethvlendiamine     from     stomach-contents, 
I       628         . 
Eucasin,  196 
Evacuation  of  stomach,  139 

delayed,  140 
Ewald  and  Boas,  test-breakfast  of.  95,  207 

and  Sievers.  method  of,  for  testing  motor 
function  of  stomach,  134 

enema  of,  219 

Einhorn  stomach-lamp  of.  59 

on  toxin  from  the  urine,  629 

Politzer  bag  of,  91 

salol  test  of.  134 
Excitant  diet  in  myasthenia  gastrica,  215 

treatment  of  adenasthenia,  303 
Excitation  in  myasthenia  gastrica,  215 

of  asthenia  gastrica,  256 
Exercise,  163 

effect  of,  246 

in  myasthenia  with  stagnation,  362 
Exhaustion  stage  of  anorexia,  273 
Exophthalmic  goiter,  vomiting  in,  326 
Expectant  treatment,  'sz 
Expression  method  of  removing  the  stom- 
ach-contents, 93 


Fai.sk  hunger,  44 
Farad ic  brush,  246 
Faradism  in  myasthenia  gastrica,  244 

selection  of  poles  in,  241 
Fatigue   in   consumption  of    potential  en- 
ergy, 175 
Fats,  210 

digestion  and  absorption  of,  182 

in  adenasthenia,  303 

in  cancer  of  stomach.  553 

in  catarrhal  gastritis.  411 

in  gastric  fermentation,  216 

in  gastric  sensibility,  213 

in  gastroptosis.  574 

in  myasthenia  with  retention,  375 


INDEX. 


659 


Fats  in  myasthenia  with  stagnation,  360 

in  neurasthenia  gastrica,  346 

in  obstruction  of  pylorus,  605 

in  subacidity,  214 

nutritive  value  of,  175 
Fay   on     sulphate  of   anilin    in    cancer  of 

stomach,  551 
Fecal  vomiting    in     fistula    from     gastric 

ulcer,  496 
Feces  as   a   measure  of  degree  of  pyloric 
retention,  604 

swallowing  of,  271 
Feeding,  artificial,  187 

forced,  1S7 

through  gastric  fistula,  583 
Fenwick  on  anorexia  nervosa,  272 
Fermentation,  acute  gastric,  3S3 

gas-forming,  in  pyloric  obstruction,  589, 
596 

gastric,  147-154.  258 

in  cancer  of  stomach,  533 

in  glandular  gastritis,  417 

in  myasthenia  with  retention,  365 
with  stagnation,  351 

lactic.    See  Lactic  termeyitatioii. 

lactic    acid.     See   Lactic  fermentation. 

meat  diet  in,  194,  195 

sounds,  76 

theory  of  nutrition,  169 
Ferments,  119-12S 
Fever,  gastric,  3S9 

in  cancer  of  stomach,  539 
Fibrin  formation  in  cancer  of  stomach,  536 
Fibroid  dysciasia,  565 
Fibroma  of  the  stomach,  511,  544 
Fibromyoma  of  tlie  stomach,  511 
Finger  method  of  introducing  the  stomach- 
tube,  90 
Fish,  196 

-hook  variety  of  stomach   displacement, 

.559 

in  bulimia,  269 

in  cancer  of  stomach,  553 

in  catarrhal  gastritis,  412 

in  gastritis  glandularis  atrophicans.  441 

in  gastroptosis,  574 
with  neurasthenia,  576 

in  hyperchlorhydria,  294 

in  hypersthenic  gastritis,  4.27 

in  myasthenia  with  retention,  375 
with  stagnation,  361 

in  neurasthenia  gastrica,  346 

in  obstruction  of  pylorus.  605,  607 
Fistula  as  a  sequel  of  ulcer  ot  stomach,  496 
Flabby  abdominal  wall  as  cause  of  gastrop- 
tosis, 565 
Flaked  hominy,  209 

rice,  209 
Flatulency,  42,  155,  156,  224,  225 

in  gastroptosis,  567 

in  myasthenia  with  retention,  364 

in  spasm  of  the  pylorus,  312 
Fleiner  on  anorexia,  275 

on  bismuth  in  ulcer  of  stomach,  504 

on  toxins  from  gastric  contents,  629 

on  use  of  bismuth,  295 

on  use  of  subnitrate  of  bismuth,  428 
Fleischer   test  for  motor  function  of  stom- 
ach, 135 
Floating  viscera,  250 
P'lora  of  the  stomach,  143 
Fluids  in  catarrhal  gastritis,  412 
Food.    See  Diet. 

as  a  remedy,  212-217 

constituents  of,  176,  177 

digestibility  of,  188-192 

in  asthenia  gastrica,  256 

indigestible  residuum  of,  177 


Food,  length  of  sojourn  of,  in  stomach,  18S 

physiological  action  of,  192-212 

preparations,  195,  196 

value  of,  to  organism,  176 
Forced  feeding,  187 

Foreign  body  obstructing  the  pylorus,  5S5 
Formic  acid,  poisoning  by,  395 
Fowler's  solution  in  anore.xia,  275 
Fox  on  influence  of  sex  in  cancer  of  stom- 
ach, 514 
Free  hydrochloric  acid,  101 
Freudenreich  on  milk,  197 
Friedlieb's  apparatus,  233 
Fruits,  211 

in  gastric  fermentation,  216 

in  gastritis  glandularis  atrophicans,  441 

in  gastroptosis,  574 
with  chronic  colitis,  575 
with  neurasthenia,  526 

in  hyperchlorhydria,  294 

in  myasthenia  with  retention,  375 
with  stagnation,  361 

in  obstruction  of  p\lorus,  605,  607 

in  ulcer  of  stomach,  502 
Functional  disease  of  stomach,  milk  diet 
in,  201 

disorders,  262 

signs,  Si 


Gall-bladdkr,  disease  of,  as  a   cause  of 
stomach  disease,  634 
tumor  of,  544 
Gall-stone  as  a  cause  of  stomach  disease, 

634 
colic,  27S 

obstruction  of  pylorus  by,  5S5 
Galvanism  in  myasthenia  gastrica,  244 
intragastric,  in  gastritis,  281 
selection  of  poles  in,  241 
Galvanization,  cervico-esophageal,  310 
cervicogastric,  243 

in  spasm  of  the  pylorus,  313 
dorsogastric,  302 
in  asthenia  gastrica,  242 
in  excessive  peristalsis,  316 
in  gastralgia,  277,  281 
in  gastrospasm,  315 
in  hyperesthesia  gastrica.  2S4 
in  hypersthenia  gastrica,  245 
in  nervous  vomiting,  332 
of  the  spine,  243 
recto-abdominal,  244 
spinogastric,  245,  246 
Ganglionic  cells,  264,  265 
Gas  formation,  155-157 
-forming  fermentation  in  pyloric  obstruc 

tion,  589,  596 
in  subphrenic  abscess,  490 
ill  th»  stomach,  225 
Gastralgia  nervosa,  275-2S1 

caused  by  arteriosclerosis,  635 

clinical  description,  276 

diagnosis.  278 

differential  diagnosis,  278 
from  ulcer,  478 

electricity  in,  245 

etiology,  276 

galvanization  in,  277 

malarial,  276 

treatment,  280 

urine  in,  277 
Gastric  carcinoma,  69 
clapping,  78,  79 
crises,  276 

of  locomotor  ataxia,  640 
digestibility  a  dietetic  guide,  216 
fermentation,  47,  147-154,  558 


66o 


/XDEX. 


Gastric  feinieiilation,  ilit-l  in,  216 
fever,  3S9 
clinical  description,  390 
diagnosis,  390 
treatment,  391 
fistula,  feeding;  throiigli,  583 
flatulency,  224.  225 

syniptumatic  treatment,  253 
glands,  atrophy  of.      See  Gastritis  glan- 
dularis attophicans. 
irritability  ol,  351 
gurgling,  77 
hemorrhage,  158 
from  brain  injury,  642 
in  cancer  of  stomacli,  525 
in  ulcer  of  stomach,  463 
hyperesthesia.     See   Hyperesthi'sia  gas- 

trica. 
irritation,  254 

juice,  action  of,  on  albumin,  17S 
germicidal  power  of,  142 
to.xicity    of,    in    diseases   of   stomach, 
611 
muscle  in  digestion,  130 
muscular  sense,  270 
neurasthenia.      See    Neiiraslheuta    gas- 

trica. 
pain,  41,  251 
phosplialuria,  621 
putrefaction,  154,  155,  194 

diet  In,  216 
retention  as  a  cause  of  gastroptosis,  565 

use  of  water  in,  228 
splashing,  7S-S0 

in  myaslhenia  with  retention,  367 
in  pyloric  obstruction,  594 
stimulation  in  subacidily,  214 
symptoms,  35 
tenderness,  67 
tetany,  625 

ulcer.     See  Ulcer  of  stomach. 
vertigo,  625 
Gastritis,  378-442 
acute,  378 
diet  in,  217 
milk  diet  in,  201 
mycotic,  382 

fermentation  form,  383 
infectious  forms,  386 
purulent,  387 
simple,  378 

clinical  description,  380 
diagnosis,  381 
pathological  anatomy,  379 
treatment,  382 
toxic,  391 
as  a  cause  of  myasthenia  gastrica,  349 
catarrhalis  chronica,  402 
clinical  description,  405 
diet  in,  411 

differential  diagnosis,  409 
differentiation  of,  from  adenasthenia 
gastrica,  409 
from  cancer  of  stomach,  550 
from  myasthenia  gastrica,  359,  409 
from  neurasthenia  gastrica,  409 
pathological  anatomy,  402 
prognosis,  40S 
symptomatology,  406 
treatment,  410 
caused  by  arteriosclerosis,  635 
chronic,  398 
asthenic.      See    Gastritis    calarrluxlis 

chronica. 
etiology  of,  399 

hypersthenic.     See    Gastritis    glandu- 
laris pi  oliferans. 
pathological  anatomy  of,  399 


Gastritis,  dlfTerenliation  of,    from   adenas- 
thenia gastrica,  302 
from  gastralgia,  279 
from  hyperclilorliydria,  292 
from  neurasthenia  gastrica,  343 
diphtheric,  387 
electricity  in,  240-245 
from  chlorosis,  637 
from  empyema,  645 
from  pneumonia,  645 
gastrospasm  in,  314 
glandularis  atrophicans,  430 
anemia  in,  435 
clinical  description,  434 
compensation  in,  434 
diet  in,  441 

differential  diagnosis,  437 
differentiation  of,  from  adenasthenia 
gastrica,  437 
from  carcinoma,  43S 
from  gastritis  catarrhalis  chronica, 

439 
inanition  in,  435 
leukopenia  in,  436 
patliological  anatomy,  431 
physical  signs  in,  436 
prognosis,  439 
symptomatology,  435 
test-breakfast  in,  436 
treatment,  440 
proliferans,  414 
appetite  in,  417,  418 
clinical  description,  416 
diagnosis,  423 
diet  in,  425 

differential  diagnosis,  423 
differentiation  of,  from  carcinoma,  423 

from  myasthenia,  424 
fermentation  in,  417 
functional  signs  in,  419 
hydrochloric  acidity  in,  420,  421 
pain  in,  419 

pathological  anatomy,  414 
symptomatology,  418 
test-meal,  420,  421 
treatment  of,  425 
urine  in.  422 
vomit  in,  422 
hot  water  in,  229 
hypersthenic,  diet  in,  213,  214 
differentiation    of,    from     myasthenia, 
369 
rectal  feeding  in,  221 
relation  of,  to  cancer  of  stomach,  518 
Gastrocardiovascular  symptom-groups,  622 
Gastroduodcnal  crises,  639 
Gastro-enteroptosis,  613 
Gastro-enterostomy  in  cancer  of  stomach, 
524.  553 
in  pyloric  obstruction,  608 
in  ulcer  of  stomach,  509,  511 
Gastrograph  of  Einhorn,  139 
Gastrohepatic  omentum,  50 
Gastro-intestiiial  respiration,  43 
Gastrolitli,  obstruction  of  pylorus  by,  585 
Gastroneurastbenic,  the,  i6j 
Gastrophrenic  ligament,  50 
Gastroplegia,  33s 
diagnosis  of,  from  retention  myasthenia, 

369 
Gastro[)tosis,  5,64-576 
abdominal  belt  for,  251 
clinical  description,  566 
definition,  564 
diet  in,  574 

differential  diagnosis,  570 
differentiation  of,  from  byperchlorhydria, 
292 


lAWEX. 


66 1 


Gastroptosis,  differentiation  of,  from  myas- 
thenia,  357,  571 
from  neurasthenia  gastrica,  344 
from  obstructive  stagnation  and  reten- 
tion, 371 

etiology,  564 

gastric  retention  a  cause  of,  565 

in  myasthenia,  371 
with  retention,  371 

in  pyloric  incontinence,  333 

influence  of  heredity  in,  565 
of  various  diseases  upon,  564,  565 

motor  insufficiency  in,  567 

objective  signs,  569 

prognosis,  572 

replacement  of  stomach  in,  572 

rest  in,  164 

retention  in,  567 

stagnation  in,  567 

symptomatology,  568 

treatment,  572 

uric  acid  formation  in,  567 

with  chronic  colitis,  treatment,  575 

with  myasthenia,  treatment,  574 

with  neurasthenia,  treatment,  575 
Gastrorrhea,  18 
Gastroscope,  61 
Gastrospasm,  314,  315 

caused  by  arteriosclerosis,  635 

diagnosis,  315 

diet  in,  315 

electricity  in,  245 

etiology,  314 

treatment,  315 
Gastrosplenic  omentum,  50 
Gastrostomy,  188 

in  cancer  of  cardia,  553 

in  obstruction  of  cardia,  583 

in  pyloric  obstruction,  60S 
Gastrosuccorrhea,  285 

continua  chronica,  285 

periodica,  285 
Gastroxia,  299 
Gastroxynsis,  299 

Gavage  in  nervous  vomiting,  332,  333 
Gelatin  as  a  food,  183 

in  gastric  fermentation,  216 
Gelatinous  degeneration  of  medullary  can- 
cer of  stomach,  518 
Gelsemium  in  gastralgia,  280 

in  gastric  pain,  251 
General  medication,  161-261 

secretion  of  the  stomach,  128,  129 
Genital   organs,   examination  of,  in  myas- 
thenia gastrica,  342 
'      Gentian  in  adenasthenia  gastrica,  303 

in  asthenia  gastrica,  256 
Germ  growth,  lavage  in,  231 

-products,  147 

as  gastric  irritants,  254 
Germain  See,  test-meal  of,  96 
Germicidal  activity  of  stomach,  212 

power  of  the  gastric  juice,  142 
Germs,  exclusion  of,   from  stomach,  258 

of  the  stomach.  142-157 

removal  of,  from  stomach,  258 
Glan,  spectrophotometer  of,  125 
Glands  of  the  stomach,  82,  83,  84 
Glandular  atrophy.    See  Gastritis  glandu- 
laris atrupliicaiis. 

gastritis,  414 
Glenard,  gliding  method  of,  77,  78,  80 

on  displacement  of  stomach,  566 

on  duodenal  tenderness,  67 

on  influence  of  enteroptosis  on  stomach, 
633 

pelvic  belt,  250 


Gluten  suppositories  in  hyperchlorhydria, 
29.5 

Glycerin  suppositories  in  hyperchlorhydria, 
295 

Goldschmidt   method  of  estimating  stom- 
ach-contents, 133 

Goose,  195 

Gorse,  investigations  of,  188 

Gout  as  a  cause  of  stomach  disease,  638 
use  of  water  in,  227 

Grape  juice  in  obstruction  of  cardia,  5S3 

Grapes,  211 
in  gastroptosis  with  chronic  colitis,  575 

Greater  curvature  of  stomach,  52 

Green  ve.getables,  211 

Greenfeld  on  cancer  of  stomach,  513 

Griesinger  on  frequency  of  cancer  of  stom- 
ach, 512 

Grimm  on  the  vomiting  center,  132 

Gross'  apparatus,  92 

Grouse,  195 
in  obstruction  of  pylorus,  605 

Griitzner,  investigations  of,  218 
method  of,  123 

Giinzburg,  86 
reagent  of,  103 


Haberlin  on  frequency  of  cancer  of  stom- 
ach, 512 

on  intiuence  of  sex  in  cancer  of  stomach, 
514 

on  mortality  from  cancer  of  stomach,  513 
Habitual  regurgitation,  321,  322 
Hacker    on    pylorectomy     in     cancer    of 

stomach,  554 
Hallot,  method  of  Mathieu  and,  137 
Hammerschlag,  method  of,  124 

on  lactic  fermentation  in  cancer  of  stom- 
ach, 535 
Hammerschlag's  test,  95 
Hard-boiled  egg,  207 
Hard  cancer  of  stomach,  516 
Hauser  on  ulcer  of  stomach,  443 
Hauswaldt's  vigor  chocolate,  294,  361.     See 

Vigor  chocolate. 
Hayem  and  Winter,  method  of,  11 1 

on    gastritis    favoring    development    of 
tuberculosis,  646 

on  lactic  fermentation  in  cancer  of  stom- 
ach, 535 

on  secretion  in  ulcer  of  stomach,  474 

on  ulcer  of  stomach,  447 

theory  of,  98,  116 
Headache    in    digestive   hyperchylia  gas- 
trica, 295 

in  gastroptosis,  567,  569 

in  paroxysmal  hyperchylia,  300 
Heart,  action  of,  in  obstruction  of  cardia, 
581 

diseases  of,  as  causes  of  stomach  disease, 
634 

influence  ol  diseases  of  stomach  on,  621 

insufficiency   of,  as   a  cause   of  stomach 
disease,  635 

sounds,  76 
Heartburn,  38 

in  gastralgia,  277 

in  gastroptosis,  567 

iti  hyperchlorhydria,  288 

iti  neurasthenia  gastrica,  339 
Heat-production  in  the  body,  173-175 

-units,  173-175 
Hectic  fever  in  subphrenic  abscess,  493 
Heizmann  on  frequency  of  cancer  of  stom- 
ach, 512 


662 


INDEX. 


HeitiHtcincsis   in  cancer  of   stomach,  525 

ill  ulcer  ol  stomach,  463 
Hemalocylolysis,  614 
Hematogenous  vomiting,  326 
Hemi-albumose,  178 
Hemianopia  in  pyloric  obstruclioii,  592 
Hemi|ieptone,  178 
Hemmeter,  apparatus  of,  139 
Hemoglobin,  diminulioii  of,   in   cancer  of 

stomach,  536 
Hemophilia  as  a  cause  of  gastric   hemor- 
rhage. 636 
Hemoptysis,  467 

Hemorriiage,    esophageal,    differentiation 
of,  from  gastric  hemorrhage,  468 

gastric, clifferentialion  of,  from  leukemia, 
636 
from  pulmonary  hemorrhage,  467 

in  cardiospasm,  30S 

in  gastric  ulcer,  treatment,  504 

in  ulcer  of  stomach,  463 

rectal  feeding  in,  221 
Hemostatics   in     hemorrhage    of    gastric 

ulcer,  504 
Hepatic  colic,  40 

Heryiig  illumination  of  stomach,  58 
Hetero-alhumose,  293 
Hiccup  in  subphrenic  abscess  from  ulcer  of 

stomach,  492 
Hlasko  on  motor  centers  of  the  stomach, 

132 
HofTman's  anodyne,  280 
Hot  drinks  in  spasm  of  pylorus,  314 
water,  action  of,  on  stomach,  228 
for  vomiting,  253 
in  bulimia,  269 
in  gastritis,  229 
Hour-glass  deformity  of  the  stomach,  497 
Huber  on    tests    for    motor    insufficiency, 

134 
Hueppe  on  bacillus  butyricus,  152 
Hunger-center,  266-269 
Hunger,  false,  44 

in  obstruction  of  cardia,  579 

Hydrastinin  in  gastroptosis,  574 

with  chronic  colitis,  57.S 

in  pyloric  incontinence,  335 

muriate  in    myasthenia  with  stagnation, 

363 
Hydrocephalus,  vomiting  in,  326 
Hydrochloric  acid,  98 

and  pepsin  in  catarrhal  gastritis,  414 

in   gastritis  glandularis  atrophicans, 
441 
estimation  of  the  amount  of,  secreted, 

99,  100 
excessive  secretion  of,  116,  287-295 
ill  adenastlienia,  301 
in  combination  with  proteids,  104 
in  hypochylia,  260,  261 
in  milk  diet,  199 
in  rumination,  325 

ill  treatment  of  cancer  of  stomach,  552 
neutralization  of,  260 
poisoning  by,  394 
qualitative  tests  for,  loi 
quantitative  estimatiiiii  of,  105 
secretion  of,  in  cancer  of  stomach,  531 

in  myasthenia  gastrica,  355 

in  pyloric  obstruction,  596 
theories  of  formation  of,  98 
with  pepsin  in  adenastheiiia  gastrica, 

303 
acidity,  37 
in  differentiation  of  pyloric  from  duo- 
denal obstruction,  601 
in  hyiiersthenic  gastritis,  420,  421 
aiiacidity,  117 


Hydrochloric  heartburn,  351 
secretion  in    difierentiation  between  be- 
nign and  malignant  pyloric  obstruction, 
602 
subacidity,  117 
superacidity,  286 

in  ulcer  of  stomach,  474 
influence  i>f,  on  ulcer  of  stomach,  449 
Hydrogen  siilphid  as  a  diagnostic  sign,  155 
formation    in    differentiation    between 
benign  and  malignant   pyloric  ob- 
struction, 602 
of,  in  stomach,  611 
in  cancer  of  stomach,  53s 
in  pyloric  obstruction,  596 
Hydrotherapy,  34,  235 
111  anorexia  nervosa,  275 
in  eriictatio  nervosa,  320 
in  excessive  peristalsis,  316 
in  gastroptosis,  574 

with  neurasthenia,  574 
in  myasthenia  with  stagnation,  362 
in  nervous  vomiting,  331 
Hyfirothionemia   from   intestinal    obstruc- 
tion, 633 
Hyoscyamus,  extract  of,  269 
in  cardiospasm,  310 

oil  of,  in  gastroptosis  with  chronic  colitis, 
575 
Hyperacidity,  286 
Hyperazoturia,  618 
Hyperchlorhydria,  287-295 
albumins  in,  289 
clinical  description,  2S8 
diagnosis,  290 
diet  in,  293 

differential  diagnosis,  291 
differentiation  of,  from  hyperchylia,  297 
electricity  in,  293 
ferments  in,  289 

from  hypertrophic  cirrhosis,  634 
from  nejihritis,  639 
from  spinal  disease,  640 
heartburn  in,  2S8 
in  cerebral  disease,  642 
in  melancholia,  642 
labferment  in,  289 
labzymogen  in,  289 
rest  in,  288,  293 
splashing  in,  289 
symptoms  of,  288 
thirst  ill,  2S8 
treatment,  293 
Hyperclulia  gastrica,  287,  295-300 
chemical  treatment,  259 
digestive,  295-299 
diagnosis,  297 
differential  diagnosis,  297 
etiology,  295 
gurgling  in,  296 
splashing  in,  296 
treatment,  298 
from  cerebral  fatigue,  642 
paroxysmal.  299.  300 
clinical  description,  299 
diagnosis,  300 
etiology,  299 
treatment,  300 
Hyperesthesia  gastrica,  281-284 
and  gastralgia,  279 
diagnosis,  283 
diet,  284 

differential  diagnosis,  283 
etiology,  281 
from  hysteria,  643 
hot  compress  in,  235,  236 
in  neurasthenia  gastrica,  339 
treatment,  284 


INDEX. 


663 


Hypetorexia,  266,  267 

Hyperstheiiia  gastiica,  effect  of,  on  stom- 
ach, 212 
electricity  in,  245 

Hypersthenia  gastiica,  massage  in,  247 
physiological  treatment  of,  254 

Hypersthenic  gastritis,  j8,  414 

Hypertropliy  of  pylorus,  585,  5S8 

Hypochlorhydria  from  neurasthenia,  643 

Hypochondriasis  in  myasthenia  with  reten- 
tion, 366 

Hypochylia,  chemical  treatment  of,  260 
in  cancer  of  stomach,  532 

Hypogastric  belts  in  gastroptosis,  573 

Hysteria,  anorexia  in,  273 
as  a  cause  of  stomach  disease,  643 
bulimia  in,  266 

Hysterical  vomiting,  327 


Ice  in  treatment  of  hemorrhage  of  gastric 
ulcer,  504 
-water  metliod  of  I.eube,  93 
Icterus,  catarrhal,  influence  of,  on  stomach 
disease,  634 
in  myasthenia  with  retention,  366 
Illumination  of  stomach   in    diagnosis   of 
cancer,  541 
in  gastroptosis,  570 
Immediate  symptoms,  36 
Immobilization   in   treatment   of   ulcer    of 

stomach,  499 
Inanition.     See  Emaciation,  Snbnnirition, 
Cachexia. 
-anemia  from  disease  of  stomach,  615 

in  ulcer  of  stomach,  472 
delirium,  273 
in  anorexia  nervosa,  273 
in  glandular  atropln-,  435 
Incontinence  of  pylorus,  333 
Indican  in  urine,  226 

of  cancer  of  stomach,  53S 
Indicanuria  in  intestinal  disease  from  dis- 
ease of  stomach,  613 
in  intestinal  obstruction.  633 
Indications  for  the  use  of  stomach-tube, 88 
Individualization,  192 
Indol  in  the  stomach,  155 
Inflation  of  stomach,  72-74 

for  diagnosis  of  cancer.  541 

in  gastroptosis,  569 

in  vertical    displacement  of  stomach, 

562 
Strauss'  apparatus  for,  73 
test  in  p\  loric  incontinence,  334 
Influenza  as  a  cause  of  myasthenia  gastrica, 

348 
Inorganic  foods,  177 
Insomnia  in  gastroptosis,  567 
Inspection,  53 

Insufiiciency  of  stomach,  139 
Insufficient  diet,  172 
effect  of,  186 
use  of,  1S6 
Intercostal  neuralgia,  27S 
Interrogation  in  diagnosis,  27 
Interscapular  pain  in  cancer  of  stomach, 

524 
Intestinal  colic,  279 
diet,  217 
fermentation   from   disease   of  stomach, 

613 
putrefaction  from   disease    of   stomach, 
6>.3 
meat  diet  in,  194 
Intestines,  examination  of,  in  neurasthenia 
gastrica,  342 
in  digestion,  222 


Intestines,  influence  of  diseases  of,  on  dis- 
eases of  stomach,  632 
of  diseases  of  stomach  upon,  611 
Intragastric  asepsis.  499 

douche  or  spray.  234 
tube  of  Rosenheim,  234 

electrization,  244 

electrode,  Rosenheim's,  238 

faradization  in  nervous  vomiting,  332 
in  regurgitation,  322 

galvanism  in  gastralgia,  2S1 

noises,  77 
Intramural  ganglia,  electric  excitation,  243 
lodid   of  sodium  in  obstruction  of  cardia, 

5S3 
lodin  in  nervous  vomiting,  332 
Ipecac  in  gastroptosis.  574 

in  gastroptosis  with  chronic  colitis,  575 

in  hypersthenia  gastrica,  257 

111  myasthenia  with  stagnation,  363 

in  vomiting,  253 
Iron  in  neurasthenia  gastrica,  346 

subsulphate.     See  Subsulphate  of  iroit. 
Irritants  in  excessive  secretion,  214 
Isolation  in  anorexia  nervosa,  275 

in  neurasthenia  gastrica,  345 

in  treatment  of  nervous  vomiting,  331 


Jacobson,    toxin     extracted     from    urine, 

629 
Jactitation   in   myasthenia  with  retention, 

366 
Jaffe  on  diagnosis  of  subphrenic  abscess, 

494 
Jaksch  on  ulcer  of  stomach,  443 
Jaworski  and  Korcynski  on  ulcer  of  stom- 
ach, 443 

method  ot,  for  estimaiing  stomach  capac- 
ity, 74,  124 

sign  of,  497 

spiral  bodies  of,  159 

test-meal  of,  94 

test  of  absorption,  140 

test  of  Korcynski  and,  for  blood,  159 
Jejunostomy  in  obsiruclion  of  cardia,  583 

in  pyloric  obstruction,  60S 
Johnston's  beef  extract,  196 
Jukes,  suction  method  of,  91 


Kaulich   on   infantile   cancer  of  stomach, 

513 
Kel\  r,  202 

Keliing's  method  for  estimating  capacity  of 
stomach,  74 
of  testing  for  lactic  acid,  150 
Kern,  dispora  caucasica  of,  202 
Kidneys,  diseases  of,  as   causes   of  stom- 
ach disease, 639 
in  digestion,  222 
influence  of  disease   of   stomach   upon, 

630 
stone  in,  as  a  cause  of  stomach  disease, 

639 
tumors  of.  542 

Kissingen,  Saratoga.  258 

klemperer  on  lactic  fermentation  in  cancer 
of  stumaeh.  535 
test-meal  of,  94 

King,  method  of,  125 

Knaut    on    motor  centers  of  the  stomach, 
132 

Knee-chest  position,  62 

Kocher  on  pylorectomy  in  cancer  of  stom- 
ach, 554 

Kola  in  nervous  vomiting,  332 

Kolliker,  studies  of,  264 


664 


IXDEX. 


KiiiiiR   on   average   daily   coiisiiniption   of 

milk,  197 
Koroyiiski  ami  Jaworski,  test  of,  for  blood, 

159' 
Koumiss,  205 
Kiiline,  investigations  of,  1S8 

theory  of  digestion  of  albumin,  17.? 
Kuhu's  balloon  sound.  65.  66 

pyloric  sound,  64,  65 
Kuiiieft"'s  ethyleiidiamin.  62S 
KCussmaul  on  anorexia  nervosa,  275 

on  dessication  theory,  62S 


Labfer.ment,i99,  120-122 
Boas'  test  for,  121 
Leo's  test  for,  121 
Labsecretioii,  122 
Labzymogen,  120-122 

Lacing,  tight,  as  a  cause  of  stomacli  dis- 
placements, 566 
Lactic  acid,  147-152 

as  a  sign  of  cancer,  149 

Boas'  test  for,  132 

deYoiig's  test  for,  151 

diagnostic  value  of,  148 

fermentation.      See    Lactic  Jctmenla- 

lion. 
in  cancer  of  stomach,  481,  533 
in  differentiation  between  benign  and 

malignant  pyloric  obstruction,  602 
in  myasthenia  with  retention,  36S 
in  pyloric  obstruction,  596 
Kelling's  test  for,  100 
qualitative  lest  for,  loi 
Strauss'  test  for,  150 
Uffelmann's  test  for,  150 
fermentation,  147 
Landau,  abdominal  corset  of,  250 
Lateral  displacement  of  stomach.  See  Z>/j- 

placement  of  stomach,  vertical. 
Laudanum  in  rectal  feeding,  220 
Lavage,  229-234 
for  pain  in  cancer  of  stomach,  552 
in  arsenical  jjoisoiiing,  398 
in  catarrhal  gasti  itis,  414 
in  gastroplegia,  335 
in  myasthenia  with  retention,  375,  376 
in  retention  myasthenia,  370 
Laxatives  in  myasthenia  with  stagnation. 

363 
Lead  acetate.    See  Acetatr  of  Uati. 
Lebert  on    influence  of  sex  on   cancer  of 
stomach,  514 

on  location  of  ulcer  of  stomach,  452 

on  perforation  in  ulcer  of  stomach,  4S6, 
489 

on  ulcer  of  stomach,  443,  446 
Leiter's  gastroscope,  61 
Leo's  test  for  labferment,  121 
Lupine,  gastroxia,  299 
Lesage  on  bacillus  coli  communis,  155 
Lettuce  in  catarrhal  gastritis,  413 
Letulle  on  presence  of  bacteria  in  ulcer  of 

stomach,  449 
Leube,  enema  of,  219 

experiments  of,  1S9 

methods  of,  64,93,  124 
for  testing  motor  function  of  stomach, 
13s 

nutritive  enema,  219 

on  duodenal  ulcer,  484 

on  muscular  rheumatism,  278 

on  rest  and  Carlsbad  cure,  506,  507 

progressive  diet  of,  1S9 

-Rosenthal  apparatus,  233 
Leucin  in  the  stomach,  155 


Leukemia  as   a  cause  of  gastric     hemor- 
rhage, 363 

Leukocytes,  action  of,  on  albumin,  179 
in  blood  in  cancer  of  stomach,  537 

Leukocythemia,  digestive,  179 

Leukocytosis  from  disease  of  stomach,  616 
in  cancer  of  stomach,  536 

Leukopenia  from  subnutrition,  616 
in  glandular  atrophy,  436 
terminal.  537 

Leven  on  fats,  210,  411 
on  gastroxia,  299 

Levulose,  digestion  of,  181 

Leydeii  on  subphrenic  abscess  in  ulcer  of 
stomach,  4SS 

Liebig's  meat  extract,  196 

Lienteric  diarrhea,  334 

Ligation   in   treatment    of  gastric   hemor- 
rhage, 505 

Liiiea  alba.  53 

Lipoma  of  the  stomach,  511 

Litmus  in  testing  for  HCI,  loi 
paper,  loi 

Liver,  diseases  of,  as  a  cause  of  stomach 
disease,  633 
functions  ol.  614 
influence  of   disease   of   stomach   upon, 

614 
percussion  of,  70 
tumors  of,  544 

ulceration    of,   from    ulcer    of  stomach, 
4&S 

Locomotor  ataxia,  gastric  crises  of,  640 
periodical  vomiting  in,  329 

Loreta's   digital   divulsion  in   pyloric   ob- 
struction, 60S 

Loss  of  appetite,  251 

Louis  on  influence  of  sex  in  cancer  of  stom- 
ach. 514 

Lugols  solution.  2S9 

Liittke,  method  of,  112 

Lymphadenoma  of  the  stomach,  511 

Lymphocytes  in  cancer  of  stomach,  53S 


Magnesia,  calcined,  260 

usta,  2CO 
as  an  antidote  for  acid-poisoning,  396 
Maibaum  on  pyoktanin  in  cancer  of  stom- 
ach, 551 
Malarial  cachexia,  differentiation  of,  from 
cancer  of  stomach,  549 

gastralgia,  276 
^L^Itose,  181 
Massage.  246-250 

abdominal,  246,  247 

in  bulimia,  268 

in  digestive  hyperchylia,  298 

in  gastroptosis  with  neurasthenia,  576 

in  gastrospasm,  315 

in  myasthenia  with  retention,  374 
with  stagnation,  362 

ill  nervous  vomiting,  331 

in  neurasthenia  gastrica.  341 

reflex-acting  method,  247 
NLasturbati<in  a  cause  of  eructatio  nervosa, 

3'9 
a  cause  of  gastralgia,  276 
Mathieu  emulsion-meal,  296,  354 
method  of,  for  estimating  motor  activity 

of  stomach.  137 
on   cancer  of  stomach    before    thirtieth 
year,  513 
Matzoon,  203 

Maydl  on  subphrenic  abscess,  495 
in  ulcer  of  stomach,  488,  489 
Meat,  192-196 


INDEX. 


665 


Meat,  action  of,  oti  secretion,  193 
broth  in  ulcer  of  stomach,  502 
broths  in  morbid  sensibility,  213 
commercial  preparations  of,  195 
diet,  effect  of,  180 
in  adenasthenia  gastrica,  303 
in  cancer  of  stomach,  553 
in  catarrhal  gastritis,  412 
in  excessive  secretion,  214 

of  HCl,  194 
ill  gastric  fermentation,  216 
ill  gastioptosis,  574 

with  chronic  colitis,  575 
in  gastrospasni.  315 
in  hypersthenic  gastritis,  426 
in  myasthenia  with  retention,  375 

with  stagnation,  361 
in  neurasthenia  gastrica,  346 
in  obstruction  of  pylorus,  405 
jellies  in  myasthenia  with  retention,  375 
jelly  as  an  intestinal  diet,  217 
juice  as  an  intestinal  diet,  217 
in  cancer  of  stomach,  553 
in    gastritis    glandularis   atrophicans, 

441 
in  obstruction  of  cardia,  583 
powder,  196 
as  an  intestinal  diet,  217 
in   gastritis    glandularis    atrophicans, 

441 
in  myasthenia  with  retention,  375 
in  obstruction  of  cardia,  583 
in  ulcer,  ,soS 
preparations,  195 
pulp  in  pyloric  obstruction,  607 
raw,  195 
Medullary  carcinoma  of  the  stomach,  517 
Melancholia   in  vertical    displacement    of 

stomach,  561 
Melena  in  ulcer  of  stomach,  466 
Meltzer,  experiment  of,  239 
Meltzing's  method  of  palpation,  64 

of  stomach  illumination,  60 
Meningitis,  cerebral,  as  a  cause  of  vomit- 
ing, 641 
spinal,  as  a  cause  of  stomach  disease,  640 
vomiting  in,  326 
Menorrhagia,  bulimia  in,  266 
Menthol  for  vomiting,  253 
in  gastric  pain,  252 
in  nervous  vomiting,  332 
Merycism,  188.  322-325 

Metallic   poisons,   action   of,   on   stomach, 
397 
tinkling   in   diagnosis  of  subphrenic  ab- 
scess, 494 
Metastatic  abscess  as  a  cause  of  subphrenic 

abscess,  495 
Method  of  Boas,  106,  121 
of  Braun,  no 
of  Chomel,  135 
of  Cseri  for  expressing  stomach-contents, 

248 
of  Debove  for  treating  gastric  ulcer,  508 
of  Dehio,  138 
ofdeYong,  151 
ofEwaldand  Sievers  for   testing  motor 

function  of  stomach,  134 
of  Goldschmidt,  133 
of  Griitzner,  123 
of  Hammerschlag,  124 
of  Hayem  and  Winter,  in 
of  Jaworski,  124 
of  Kelling,  150 
of  King,  125 
of  Leo,  121 
of  Leube,  124,  135 
of  Liittke,  112 


Method  of  Mathieu  and  Hallot,  137 

of  Mathieu  and  Remond,  133 

of  Mintz,  105 

of  Oppler  for  determining  pepsin,  126 

of   Petizoldt   and    Faber   for    estimating 
absorbability  of  stomach,  141 

of  Reibtnayer  for  massage,  249 

of  Rosenbach,  138 

of  Schiff,  123 

of  Strauss,  133,  150 

of  Topfer,  106 

of  Uftelniann   for  testing  for  lactic  acid, 
150 

of  Volhard,  112 

of  von  Zieinssen,  242 

of  Van  Valzah  and  Nisbet,  138,  140 

of  Zabludowski,  247,  248 
Methylene-blue  in  cancer  of  stomach,  551 

in  obstruction  of  cardia,  5S3 
Methyl-violet,  103,  104 

Micro-organisms,   influence   of  acidity    of 
stomach  on,  143 

of  the  stomach,  142-157 
quantity  of,  146 
Mikulicz  on  stomach  examination,  61 
Milk,  197 

action  of,  on  intestines,  200 
,  on  stomach,  199,  200 

and   neutralization    method   of   treating 
gastric  ulcer,  ,so8 

and  rest-cure  in   gastroptosis  with   neu- 
rasthenia, 576 

as  a  culture  soil,  197 

as  an  intestinal  ditt,  217 

caloric  value  of,  196 

composition  of,  198 

-cure  in  morbid  sensibility,  213 
in  ulcer  and  gastritis,  214 

diet,  200,  201 

in  acute  gastritis,  201 
in  ulcer  of  stomach,  200 
value  of,  200,  201 

effect  of,  in  gastroptosis,  567 

in  bulimia,  269 

in  cancer  of  stomach,  552 

in  cardiospasm,  309 

in  catarrhal  gastritis,  412,  413 

in  digestive  hyperchylia,  299 

in  gastritis  glandularis  atrophicans,  441 

in  gastroptosis,  574 
with  chronic  colitis,  575 

in  gastrospasni,  315 

in  hyperchlorhydria,  290,  294 

in  hypersthenic  gastritis,  426,  427,  429 

in  morbid  sensibility.  213 

in  myasthenia  with  stagnation,  361 

in  neurasthenia  gastrica,  346 

in  obstruction  of  cardia,  583 

in  subacidity,  214 

in  ulcer  of  stomach,  500-502,  508 

intestinal  digestion  of,  200 

nutritive  value  of,  197,  198 

pasteurization  of,  197 

preparations  of,  202 

quantity  of  fat  in,  205 

sterilization  of,  197 

-sugar,  181,  211 
Milky  urine,  621 

Milliot  method  of   illuminating  the  stom- 
ach, 58 
Mintz,  method  of,  105 
Mohr  buret,  108 
Moisture  of  climate,  influence  of,  174 

use  of,  235 
Montuuis,  belt  of,  250 
Moral  atmosphere,  162 

treatment  in  neurasthenia  gastrica,  345 
Moritz,  fermentation  test  tube  of,  157 


43 


666 


INDEX. 


Morphiii  ill  gastralgia,  280 
in  gastric  pain,  252 
in  hyperchylia,  300 
in  mycotic  gastritis,  386 
ill  nervous  vomiting,  332 
in  the  perforation  of  gastric  nicer,  506 
in  ulcer  of  stomach,  505 
muriate,  280 
Motor  disorders,  diet  in,  215 
dynamic  affections,  304-336 
function,  130-140 
insufficiency,  302 

in  cancer  of  stomach,  532 
in  gastroptosis,  567 
of  stomach  from  tuberculosis,  647 
Mouth,  diseases  of,  as  causes  of  gastric  dis- 
ease, 643,  644 
Movements  of  the  stomach  during  diges- 
tion, 130,  131, 132 
Mucin-toxemia,  629 
Mucous  glands  of  the  stomach,  82,  83 

secretion,  lavage  in,  231 
Mucus,  128,  129 

Muhlbrunneii  Carlsbad  water,  507 
Multiple  sclerosis  as   a  cause  of  stomach 
disease,  640 
hyperchylia  in,  300 
vomiting  in,  326 
Muscular  irritability,  diet  in,  215 
rheumatism,  27S 
sense,  gastric,  270 
work,  175 
Mush,  209 
Mutton  in  catarrhal  gastritis,  412 

in  obstruction  of  pylorus,  605 
Myalgia,  278 

Myasthenia  gastrica,  18,  27,  29,  31,  347-377 
bicarbonate  of  soda  in,  257 
butyric  acid  in,  153 
cereals  in,  209 
common  salt  in,  257 
diet  in,  215 

differentiation  of,  from  carcinoma,  373 
from  catarrhal  gastritis,  409 
from  gastroplegia,  369 
from  gastroptosis,  571 
from  hyperchlorhydria,  291 
from  hyperchylia,  297 
from  hypersthenic  gastritis,  369,  424 
from  neurasthenia  gastrica,  344 
electricity  in,  240,  244 
etiology,  348 
flatulency  in,  225 
from  diabetes,  368 
from  empyema,  645 
from  tuberculosis,  647 
gastroptosis  in,  371 
insufficient  diet  in,  186 
ipecac  and  strychnin  in,  257 
rest  in,  164 

stomach  washing  in,  229 
use  of  water  in,  228 
with  retention,  347   364-377 
clinical  description,  364 
diagnosis,  368 
diet  in,  374 

differential  diagnosis,  368 
differentiation  of,  from  gastroplegia, 

369 
from  hypersthenic  gastritis,  369 
from  obstructive  retention,  370-373 

lavage  in,  230,  275 

objective  signs,  367 

prognosis.  373 

rectal  feeding  in,  220 

treatment,  374-377 
with  stagnation,  347,  349-363 

diagnosis  of,  356 


Myasthenia  gastrica  with  stagnation,  dif- 
ferential <liagiiosis,  356 
fermentation  in,  351 
prophylaxis  of,  359 
treatment  of,  3^9 
yolk  of  egg  in,  207 
g;astro-intestinalis,  244 
iiitestinalis  in  myasthenia  gastrica,  331 
Myasthenic   stagnation.     See   Myasthenia 

with  stagnation. 
Mycoderma  aceti,  1,53 
Mycotic  gastritis,  .■?82 

fermentation  form,  383 
infectious  forms,  3.S6 
Myelitis  as  a  cause  of  stomach  disease,  640 
Myoma  of  stomach,  544 


Narcotics  as  a  cause  of  vomiting,  327 
Nausea,  42 
from  disease  of  the  intestines,  632 
in  catarrhal  gastritis,  405 
in  chronic  gastritis,  401 
in  excessive  peristalsis,  316 
in  myasthenia  with  retention,  365 
in  i)y]oric  obstruction,  592 
in  subphrenic  abscess  from  ulcer  of  stom- 
ach, 492 
Nedopil  on  frequency  of  cancer  of  stomach, 

512 
Needle-spray,  221,  237 
Needles,  swallowing  of,  271 
Neoplasms  of  stomach,  57,  5ii-5,s4 

diagnosis  of  benign  from  malignant,. ^1)4 
Nephritis  as  a  cause  of  stomach  disease, 
639 
as  a  cause  of  vomiting,  327 
influence  of  ilisease  of  stomach  on,  631 
Nervines  in  neurasthenia  gastrica,  346 
Nervous  disorders  in  pyloric  obstruction, 
593 
system,  influence  of  disease  of  stomach 
on,  624 
influence  of  diseases  of,  on  stomach,  640 
temperament,  264 
vomiting,  325,  327 
Neuralgia  in  neurasthenia  gastrica,  339 
intercostal,  278 
of  abdominal  wall,  39 
pneumogastric,  275 
Neurasthenia  as  a  cause  of  gastric  disease, 
642 
from  disease  of  stomach,  624 
gastrica,  336-347 
bulimia  in,  266 

cervicogastric  galvanization  in,  243 
differential  diagnosis,  342 
differentiation  of,  from  catarrhal  gastri- 
tis, 409 
from  myasthenia  gastrica,  356 
electric  treatment,  242 
etiological  treatment,  347 
etiology,  337 
forced  feeding  in,  187 
from  cerebral  neurasthenia,  642 
from  gastroptosis,  569 
hydrotherapy  in,  237 
ipecac  and  strychnin  in,  257 
peculiar  discomfort  in,  337 
prognosis,  ,-^44 
treatment  of,  345 
in  gastroptosis,  569 

in  vertical  displacement  of  stomach,  ,«j6i 
Neuromuscular  tonics  in  pyloric  obstruc- 
tion, 606 
Neutralization-method  of  treating  gastric 

ulcer,  ,so8 
Nickel-plated  electrode,  241 


INDEX. 


667 


Nitrate  of  silver,  252 
as  a  sedative,  255 
as  an  antidote  to  chromic  acid,  395 
douclie,  235 
in  cardiospasm,  310 
in  hyperchlorhydria,  295 
in  hypersthenia  gastrica,  284 
in  hypersthenic  gastritis,  428 
in  neurasthenia  gastrica,  346 
in  spasm  of  pylorus,  313 
in  ulcer  of  stomach,  503,  505 
Nitric  acid,  poisoning  by,  394 
Nitrogenous  waste, excessive,  from  disease 

of  stomach,  618 
Nitroglycerin  in  nervous  vomiting,  332 
Nodosities  of  Bouchard,  367 
Nolte  on  ulcer  of  stomach,  443 
Nose,   diseases   of,    as    causes   of   gastric 

disease,  644 
Nowak  on  subphrenic  abscess  in    ulcer  of 

stomach,  488 
Nutrient  enemata,  218 
Nutriment,  definition  of,  171 
Nutrition.      See     Symptoviatology     undei 
each  disease  of  stomach. 
diseases  of,  as  a  cause  of  stomach  disease, 

638 
function  of  the  cell  in,  170,  171 
in  cancer  of  the  stomach,  530 
in  pyloric  obstruction,  593 
influence  of  diseased  stomach  upon,  166 

of  diseases  of  stomach  on,  617 
needs  of  the  organism  for,  173 
theories  of,  169 
waste,  174,  175 
Nutrose,  196 
Nux  vomica  in  adenasthenia  gastrica.  303 

Oatmeal,  209 

in  pyloric  obstruction,  607 
Obesity  as  a  cause  of  stomach  disease,  638 
Objective  signs,  48 
Obsolete  terminology,  19 
Obstetrician's  hand,  626 

Obstruction    and     hyperchylia,  differentia- 
tion of,  298 
of  the  cardia,  577 

clinical  description.  578 

diagnosis,  5S1 

diet  in,  583 

etiology",  577 

heart's  action  in,  581 

influence  of  age  on,  582 

prognosis  of.  582 

surgical  treatment,  583 

swallowing  sounds  in,  580 

symptomatology,  579 

treatment,  582 
of  the  orifices  of  stomach,  576 
of  the  pylorus,  584 

bacteriological  signs  of.  596 

cancerous,  590 

clinical  description,  585 

compensation  in,  586 

degree  of,  604 

diagnosis,  597 

diet  in,  604 

differential  diagnosis,  370-373,  597 

differentiation  of,  from    duodenal    ob- 
struction, 59S,  600 

etiology,  584 

local  physical  signs  in,  594 

nervous  disorders  in,  593 

nutrition  in,  593 

period  of  compensation,  586 
of  retention,  587 
of  stagnation,  586 

prognosis,  604 


Obstruction  of  pylorus,  rules  for  feeding  in, 
606 
surgical  treatment,  608 
symptomatology,  590 
toxic  symptoms  in,  593 
treatment,  604 
of  the   stomach,  differentiation   between 

benign  and  malignant,  602 
rectal  feeding  in,  220 
.Obstructive  retention,  lavage  in,  230 

stagnation,  differentiation  of,  from  hyper- 
chylia gastrica,  600 
from  hypersthenic  gastritis,  600 
with  retention,  differentiation  of,  from 
myasthenic   obstruction    and    reten- 
tion, 598,  599 
Oertel,  227 
Oidium  lactici,  152 
Oligemia  sicca  from  diseaseof  stomach,  615 

in  cancer  of  stomach,  536 
Oligochromemia   as  a    cause   of   stomach 
disease,  363 
from  disease  of  stomach,  616 
Oligocythemia  as  a   cause   of  stomach  dis- 
ease, 637 
from  disease  of  stomach,  616 
Olive  oil,  210 
Openchowski,  dilator  fibers  of,  323 

on  motor  centers  of  the  stomach,  132 
Opiates,  252 

Opium  as  a  cause  of  vomiting,  327 
as  gastric  sedative,  255 
deodorized  tincture  of,  280 
in  acid-poisoning,  396 
in  bulimia,  268 
in  cancer  of  stomach,  551 
in  eructatio  nervosa,  320 
in  gastralgia,  280 
in  gastric  pain,  252 
in  hyperchlorhydria,  294 
in  hypersthenic  gastritis,  429 
in  the  peritonitisof  gastric  ulcer,  506 
Oppler,  method  of,  for  determining  pepsin, 
126 
on  cocci  of  stomach,  144 
Orange  juice  in  gastroptosis  with  chronic 

colitis,  575 
Orexin  in  loss  of  appetite,  251 
Orexinum  basicum,  275 
in  adenasthenia,  303 
Organic  foods,  177 
Oser  on  eructatio  nervosa,  317 
Ost's   method    for  estimating  capacity   of 

stomach,  74 
Overstudy  as  a  cause  of  neurasthenia  gas- 
trica, 338 
Oxalate  of  cerium,  253 

in  nervous  vomiting,  332 
Oxalic  acid,  poisoning  by,  395 
Oxidation  aldehyd  test  of  Boas,  132 

and  combustion  theory  of  nutrition,  16S 
Oxybutyric  acid  in  urine  of  cancer  of  stom- 
ach, 539 
Oysters,  269 
in  catarrhal  gastritis,  412 
in  hyperchlorhydria,  294 

Pain,  39 
as  a  cause  of  inanition,  187 
epigastric,  280 
gastric,  251,  275-281 
in  cancer  of  stomach,  524 

treatment  of,  552 
in    differential     diagnosis     of    ulcer    of 

stomach  and  gall-stone,  483 
in  gastric  crises,  640 
in  gastroptosis,  567,568 
in  glandular  atrophy,  435 


668 


INDEX. 


Pain  in  ^laiiilular  gastritis,  419 
ill  hypcrchyliagasirica,  295 
in  obstruction  of  cardia,5So 
in  pyloric  obstruction,  587,  591 
in  the  stomach.  39 
in  ulcer  of  stomach,  459 
in  vertical  displacement  of  stomach,  560 
Palpable  peristalsis,  315 
Palpation,  61 

Palpitation  of  heart  from  disease  of  stom-. 
ach, 622 
in  myasthenia  with  retention,  366 
in  neurasthenia  gastrica,  340 
Pancreas,  palpation  ot',  64 
tumors  of,  542 

ulceration  of,  from  ulcer  of  stomach,  487 
I'ancreatic-juice,  action  of,  on  albumin,  178 
in  digestion  offals,  182 
in  the  stomach,  160 
in  vomit,  601 
Pancreatin  in  treatment  of  atrophy  of  gas- 
tric glands.  440 
Pancreogastric  fistula,  155 

from  ulceration,  487 
Panopeptone  as  intestinal  diet,  217 
Papoid  in  gastritis  glandularis  atrophicans, 

44' 
Pariser  on  operations  for  perforating  ulcer 

of  stomach,  510 
Parorexia,  270 

treatment,  271 
Paroxysmal  hyperchylia  gastrica,  299,  300 
Pasteurization  of  milk,  197 
Pastry  in  gaslroptosis,  574 
Peaches,  211 

Pelvic  belt  of  Gl^nard,  250 
belts  in  gastroptosis,  573 
Penzoldt  and  Fabt-r,  method  of.  for  estimat- 
ing absorbability  of  stomach,  141 
method  of,  353 

of  stomach  percussion,  69 
on  action  of  meat,  193 
on  hyperchlorhydria,  293 
on  orexin,  251 
on  orexinuni  basicuni,  275 
progressive  diet  of,  190 
table  of  digestibility,  190 
Pepsin,  123-128 
Pepsinogen,  123-128 
Peptones  as  gastric  irritants,  2,>4 

as  intestinal  diet.  217 
Peptonization,  influence  of,  on  blood,  616 
Peptotoxin,  629 
Percussion,  68-72 

Perforation  from  cancerof  stomach,  520 
in  ulcer  of  stomach.  486 

treatment  of,  506 
rectal  feeding  in,  221 
Perigastritis,  236,  333 

Perinephritis  as  a  cause  of  stomach  disease, 
640 
as  a  cause  of  subphrenic  abscess,  495 
Periodical  vomiting,  329 
Peristalsis,  57 
excessive,  315,  316 
in  pyloric  obstruction,  594 
reflex  excitation  of,  247 
sounds,  76 
visible,  315,  316 
Peristaltic  movements  of  the  stomach,  131 

unrest,  319 
Peritonitis  in  gastric  ulcer,  treatment  of,  506 
plastic,  complicating  ulcer  of  stomach,  485 
Permanganate  of  potash  douche,  235 
Pfuhl     on     the    diagnosis    of    subphrenic 

abscess,  494 
Pharynx,  spasm  of,  317 
Pheasant,  195 


j    Pheasant  in  obstruction  of  pylorus,  605 
I    Pbenacetin  in  cancer  of  stomach,  5SI 

in  gastric  fever,  391 
I        in  hyperchylia,  300 

Pheiiolphthaiein,  106,  114,  115 
Phillip  on  duodenal  tenderness,  67 
Phloroglucin,  103 

-vanillin  paper,  103 
Phosphate  of  codein.  252 
in  mycotic  gastritis,  386 
in  nervous  vomiting,  332 
Phosphaturia    from    disease    of    stomach, 

617,  620,  630 
Phosphorus,  poisoning  by,  397 
Phthisis.     See  Tuberculosis. 
Physical  examination,  4S 
'        remedies,  227-251 
signs,  4S-80 
Physiological  salt  solution.  256 

treatment,  253-258 
Pig's-foot  jelly,  412 

Pineapple  in  obstruction  of  cardia,  583 
Pins,  swallowing  of,  271 
Piorry's  method  of  stomach-percussion,  69 
I    Pityriasis  versicolor  in  myasthenia  with  re- 
j        tention,  366 

Plastic    peritonitis  complicating  ulcer    of 
I        stomach,  485 

Plate  electrode,  243,  244,  245 

Pleurisy  as  a  cause  of  stomach  disease,  645 

in  ulcer  of  stomach,  493 
Pneumonia  as  a  cause  of  stomach  disease, 
645 
following  subphrenic  abscess  from  ulcer 

of  stomach,  491 
in  ulcer  of  the  stomach,  491 
Pneumothorax   as    a    sign    of  subphrenic 

abscess,  493 
Poached  egg,  207 

Points  of  reference  on  abdomen,  48,  49 
Poisoning  by  acids,  392 
by  antimony,  treatment  of,  398 
by  arsenic,  treatment  of,  398 
by  caustic  alkalies,  396 
by  metals,  397 
by  sulphuric  acid,  394 
Poisonous  acids  as  a  cause  of  gastritis,  392 
Polar  difference,  241 
Poles,  difl'erence  between,  241 

selection  of,  241 
Politzer  bag  of  Ewald,  91 
Polyadenonia  of  the  stomach,  511 
Polyphagia,  26S 
Pork, 195 

Potain  on  gastrocardiovascular  symptom- 
group,  623 
Potassium  broniid  in  cardiospasm,  310 
Potatoes,  210 

Potential    energy,   atisorption   of,    by   the 
body,  173-175 
consumption  of,  in  fatigue,  175 
Pott's  disease  a  cause  of  cardiospasm, 308 
Poultices,  hot,  in  gastralgia,  280 
Poultry  in  gastritis  with  chronic  colitis. 575 

in  gastroptosis  with  neurasthenia.  576 
Prazmowski  on  bacillus  biityricus,  152 
Pregnancy  as  a  cause  of  gastroptosis,  565 

as  a  cause  of  vomiting,  327 
Prepared  foods,  table  of,  196 
Prescription  of  diet,  223 
Present  symptoms,  35 
Previous  history,  .^o 
I'riessnitz  compress,  236 
Primary  gastrospasni,3i4 
"  Primordial  basis."   170 
Progressive  diet  of  Leube.  189 

of  Penzoldt,  190 
Propeptones  in  asthenic  gastritis,  407 


INDEX. 


669 


Propeptones  in  hypersthenic  gastritis,  420 
Proteids,  digestion  of,  142 
Protein-chroniogen,  178 
Protoplasm,  chemical  composition  of,  170 
Prunes,  211 
Psychic  vomiting,  328 
Ptyalin,  action  of,  on  starch,  181 
Pulmonary  tuberculosis  as  a  cause  of  stom- 
ach disease,  646 
Pulse  in  perforation  of  stomach  from  ulcer, 

487 
Purgatives  in  hyperchlorhydria,  295 
Purjesz's  method  of  measuring  stomach,  71 
Purulent  gastritis,  387 
Pus  in  esophageal  regurgitation.  322 
Putrefaction,  154,  155 

in  the  stomach,  47 

meat  diet  in,  194 
Putrefactive  bacteria,  147 
Pyelitis  as  a  cause  of  vomiting,  327 
Pylorectomy  in  cancer  of  stomach,  553 

in  pyloric  obstruction,  608 
Pyloric  evacuation  sound,  75 

glands  of  the  stoinach,  82 

incontinence,  333-335 

obstruction,    584.      See     Obslruction    0/ 
pylorus. 

orifice  of  stomach,  51 

stenosis  from  carcinoma  of  gall-bladder, 
334 
Pyloroplasty  in  pyloric  obstruction,  608 

in  ulcer  of  stomach,  509 
Pylorus,  auscultation  of,  75 

congenital  atresia  of,  584,  587 

hypertrophy  of,  585,  588 
differentiation    of,   from   annular  scir- 
rhus,  545 

incontinence  of,  333 

obstruction  of,  576,  584 

palpation  of,  62 

spasm  of,  311-314 
Pyoktanin  in  cancer  of  stomach,  551 
Pyopneumothorax  in  abscess  of  the  lung 
following  ulcer  of  the  stomach,  494 

in  ulcer  of  stomach,  493 

Quail,  195 

in  obstruction  of  pylorus,  605 
Qualitative  tests  for  hydrochloric  acid,  loi 
Quantitative  analysis  for  acids  in  the  stom- 
ach, 105 
Quassia  douche,  235 
Quinin,  252 

bimuriate,  281 

in  anorexia  nervosa,  275 

in  gastralgia,  280 

in  myasthenia  with  stagnation,  363 

in  rumination,  325 

muriate,  280 


Rasmussen  on  tight  lacing  as  a  cause  of 

ulcer  of  stomach,  447 
Ratimmow  on   pylorectomy   in   cancer  of 

stomach,  554 
Raw  meat,  195 
Reagent  of  Giinzburg,  103 
Rectal  feeding,  217-221 

in  anorexia,  275 

in  cancer  of  stomach,  553 

in  digestive  hyperchylia,  299 

in  excessive  secretion,  214 

in  gastric  putrefaction,  216 

in  pyloric  obstruction,  6o5 

in  ulcer  of  stomach,  508 
Recto-abdominal  galvanization,  244 
Red  blood  corpuscles  in  cancer  of  stomach, 
537 


Red  blood-corpuscles,  inrtuence  of  disease 
of  stomach  on,  616 

litmus  paper,  101 

meats,  194 

it]  hyperchlorhydria,  287 
"  Red  nose"  from  disease  of  stomach,  630 
Referred  pain,  39 
Reflex  vomiting,  327 
Reflexes  in  gastric  tetany,  626 
Regurgitation,  43 

esophageal,  322 

habitual,  321,  322 

in  obstruction  of  cardia,  579 
Reibmayer  method  of  massage,  249 
Reichman,  illumination  of  the  stomach,  58 
Reichmann's  disease,  18,  285,  418 
Reniastication,  322-325 
Removal  of  germs  from  stomach,  258 

of  stomach-contents,  91 
Resorcin  in  gastric  pain,  252 

Merck's  resublimated,  253 

resublimated,  in  pyloric  obstruction,  606 

resublimed,  258 
Respiratory  disorders  in  pyloric  obstruc- 
tion, 593 

gurgling,  77 

in   vertical   displacement   of   stomach, 
562 
Rest,  217 

and  Carlsbad  cure  in  gastric  ulcer,  506 

in  anorexia,  275 

in  bulimia,  268 

in  cancer  of  stomach,  551 

in  digestive  hyperchylia,  298 

in  eructatio  nervosa,  320 

in  excessive  peristalsis,  316 
,     in  gastrotopsis,  573 

with  neurasthenia,  575 

in  hyperchlorhydria,  288,  293 

in  nervous  vomiting,  331 

in  neurasthenia  gastrica,  345 

in  treatment  of  gastric  ulcer,  500 

influence  of,  164 
Resublimed  resorcin,  258 
Retention,  19,  33 

acetic  acid  in,  153 

gas  formation  in,  156 

in  gastroplegia,  335 

in  gastroptosis,  567 

in  pyloric  obstruction,  587 

in  spasm  of  cardia,  306 

lactic  acid  in,  148 

myasthenia.   See  Myasthenia  with  reten- 
tion. 

stomach  washing  in,  229 

use  of  water  in,  22S 
Rheumatism  as  acause  of  stomach  disease, 
638 

muscular,  278 

of  abdominal  wall,  39 

use  of  water  in,  227 
Rhinopharyn.v,   diseases   of,   as   causes   of 

gastric  disease,  644,  645 
Rice,  209 

flaked,  209 

in  gastroptosis  with  chronic  colitis,  575 

ill  myasthenia  with  retention,  375 

ill  obstruction  of  pylorus.  605 
Rirliet,  investigations  of,  188 
Rickets   as   a   result    of   myasthenia    with 

retention,  367 
Riegel,  test-dinner  of,  97 

in  digestive  hyperchylia  gastrica,  296 
in  hyperchlorhydria,  289 
Rigal   on   subphrenic   abscess   in   ulcer  of 

stomach,  488 
Roast  beef,  digestion  of,  193 
Roller  electrode,  243 


670 


INDEX. 


Rosacea  from  disease  of  stoniacli,  630 

Roseiibach,  method  of,  for  estimating  elas- 
ticity of  stomach,  138 

Rosenheim,  abdominal  bandage  of.  250 
electrode  of,  2J4 
gastroscope  of,  61 
intragastric  electrode  of,  238 
tube  of,  234 

Rosenthal  on  gastroxia,  299 

Rossbach  on  gastroxia,  299 

Rubiier     on     consumption     of     potenlial 
energy,  175 

Rumination,  332-325 
treatment  of,  325 


Saccharomycks  cerevisiae,  202 
Sacculation  of  esophagus,  309 
Sahli-Giinzburg  method,  86 
Salicin  as  a  gastric  antiseptic,  238 
Salicyluric  acid,  test  for,  134 
Salivary  digestion  of  starch,  181 
Salol  test  of  Ewald,  134 
Salt,  common,  in  adenasthenia,  303 

in  myasthenia,  257 
Saratoga  Kissingen,  258 
Sarcinae,  144,  145 

in  cancer  of  stomach,  53s 

in  pyloric  obstruction,  596 

ventriculi,  144 
Schiff,  method  of,  for  determining  albumin. 

123 
Schrank,  method  of,  for  detecting  H.>S,  155 
Schreiber's  balloon  sound,  66 

method  for  estimating  capacity  of  stom- 
ach, 74 
Scirrhus  of  stomach,  516 
Sclerosis,  multiple,  as  a  cause  of  stomach 

disease,  640 
Scottish  douche,  303 
Secondary  diseases  of  stomach,  631 
Secretion,  82 

dynamic  afTections  of,  285 

excessive,  lavage  in,  231 
Secretory  signs,  18 
Sedative  medication  in  hypersthenia  gas- 

trica,  235 
Sedentary  habits,  163 

Self-abuse  as  a  cause  of  neurasthenia  gas- 
trica,  338 

-inflation  of  the  stomach,  367 
Sensibility  of  the  stomach,  212 
Sexual  disease  a  cause  of  bulimia,  271 

excess  a  cause  of  eructatio  nervosa,  319 
of  gastralgia,  276 
of  neurasthenia  gastrica.  338 
of  parorexia,  271 
Signs.     See  Symptomatology. 

anatomical,  153-160 

bacteriological,  142-157 

functional,  81-142 

physical,  48-80 
Silver  nitrate.    See  A'itralf  0/  si/ver. 
Simple  bitters,  256 
Skin,  influence  of  disease  of  stomach   on. 

629 
Sleep,  influence  of,  164 
Social  atmosphere.  162 

Sodium   bicarbonate.     See  Bicarbonate  of 
soda. 

bromid.     See  Bromid  of  sodium. 

carbonate  in  acid-poisoning,  396 

chlorate.     See  Chlorate  of  soda. 

chlorid,  258 

iodid.    See  lodid  of  sodium. 
Soft-boiled  egg,  207 
Soft  cancer  of  stomach,  516 
Solar  plexus  in  digestion,  ,^36  I 


Solution  of  Boas,  103 
Somatose,  196 

as  intestmal  diet,  217 

in  myasthenia  with  retention,  375 

in  ulcer  of  stomach,  502 
Somervail.  apparatus  of,  232 
Soporifics  in  neurasthenia  gastrica,  347 
Sound,  use  of,  in  cardiospasm,  307 
Sour  foods,  212 
Soxhelet,  apparatus  of,  197 
Spallanzani,  investigations  of,  188 
Spasm  of  the  cardia,  304-311 
stagnation  from,  305 
treatment,  310 

of  the  pharynx,  317 

of  the  pylorus,  311-314 
diet  in,  313 
etiology,  312 
treatment,  313 

of  the  stomach,  314 
Spasmodic  stenosis  of  the  cardia,  308 
Spath    method    of  detecting    acid    in  the 

stomach,  86 
Spectrophotometer  of  Glan,  125 
Spinal  diseases  as  a  cause  of  stomach  dis- 
eases, 640 

meningitis  as   a   cause  of  stomach   dis- 
ease, 640 
Spinogalvanization,  243 
Spiiiogastric  galvanization,  245,  246 
Spiral  bodies  of  Jaworski,  159 

electrode,  Wegele's,  238,  239 
Splanchnoptosis,  568 
Splashing  as  a  sign  of  insufliciency,  135 

in  digestive  hyperchylia  gastrica,  296 

in  myasthenia  gastrica,  353 
with  retention,  367 

in  pyloric  obstruction,  594 
Spleen,  enlarged,  as  a  cause  of  vomiting,  636 

ulceration  of,  from  ulcer  of  stomach,  488 
Sponge-method  of  Edinger,  86 
Sporozoa  as  a  cause  of  cancer  of  stomach, 

514 
Spray,  intragastiic,  234 
Squab,  195 

in  catarrhal  gastritis,  412 

in  digestive  hyperchylia,  299 

in  hypersthenic  gastritis,  426 

in  obstruction  of  pylorus,  605 
Stagnation,  19 

acetic  acid  in,  153 

form  of  spasm  of  the  cardia,  305 

in  chronic  hypersthenic  gastritis,  421 

in  digestive  liyi)erchylia  gastrica,  296 

in  gastroptosis,  567 

in  pyloric  obstruction, 587 

myasthenia,  349-363 
Starch,  digestion  of,  181 

in  adenasthenia,  303 

in  gastric  fermentation,  216 

in  hyperchlorhydria,  289 

in  myasthenia  gastrica,  215 

in  rectal  feeding,  218 

in  subacidity,  214 
Starke  on  ulcer  of  stomach,  443 
Starvation  diet,  172 
Sleiner  on  ulcer  of  stomach,  443.  446 
Stenosis  in  gastroptosis,  567 

of  cardia.    See  Obstruction  of  rardia. 

of  pylorus.     See  Obstruction  of  pylorus. 

rectal  feeding  in,  220 
Sterilization  of  milk.  197 
Stiller  on  eructatio  nervosa,  3:7 
Stomach,  absoibability  of,  140 

action  of  caustic  alkalies  upon,  396 
of  metallic  poisons  on,  397 
of  poisonous  acids  on,  392 

adenocarcinoma  of,  517 


INDEX. 


671 


Stomach,  anatomical  diseases  of,  378 
anatomy  and  description  of,  49,  50,  51,  52 
arterial  supply  of,  464 
artificial  inflation  of,  313 
as  a  disease-producing  organ,  6ro 
auscultation  of,  75-80 
bacteria  of,  142-157 
-bucket,  Einhorn,85 
cancer  of.    See  Cancer  of  stomach. 
-contents,  methods  of  obtaining,  85 

normal,  after  test-meals,  94-98 
specific  gravity  of,   after  test-meals, 

296 
total    quantity  of,   after   test-meals, 
133 

removal  of,  91 
contraction  of,  56 
determination  of  empty,  137 
digestive  work  of,  141 
displacements  of,  554-576 

and  hyperchlorhydria,  291 
distention  of,  56 
douche  in  asthenia  gastrica,  256 
dynamic  aflfections  of,  262 
emptying  of,  by  massage,  247-249 
estimation  of  elasticity  of,  138 
evacuation  of,  139 
excessive  activity  of,  139 

secretion  by,  213 
flora  of,  143 
functions  of,  212 
gas  in,  225 
gases,  42 

germicidal  activity  of,  212 
germs  of,  142-157 
glands  of,  82,  83,  84 
immobilization  of,  in  treatment  of  gastric 

ulcer,  499 
in  the  causation  of  disease,  610 
inflation  of,  72-74 
influence  of  mind  on,  264,  265 
inspection  of,  56 
insufficiency  of,  139 
-lamp,  58,  59 

micro-organisms  of,  142-157 
motor  dynamic  aflfections  of,  304-336 
muscular  irritability,  215 
neoplasms  of,  511 
"  neuroses  "  of,  262 
palpation  of,  62-68 
percussion  of,  68-72 
scirrhus  of,  516 
secondary  diseases  of,  631 
sensibility  of,  212,  213 
spasm  of,  314 
tonicity  of,  139 
total  descent  of,  564 
transposition  of,  S54 
-tube,  22,  87,  88,  89,  90 

contraindication  to  the  use  of,  89 

in  cancer  of  stomach,  526 

in  obstruction  of  cardia,  581 

in  ulcer  of  stomach,  473 

indications  for  the  use  of,  88 

introduction  of,  89 
tumors  of,  in  cancer,  540 
ulcer  of,  442.    See  Ulcer  of  stomach. 
upward  displacement  of.     See  Displace- 
ment of  stomach,  upward.. 
vertical  or  lateral  displacement  of,  557 
vicious  circles  of,  610 
washing,  229-234 

for  removal  of  germs,  258 

in  gastric  fermentation,  216 

in  gastric  retention,  375 

in  pyloric  obstruction,  606 
Straight  form  of  vertical  displacement  of 
stomach,  560 


Strauss  method  of  estimating  tlie  stomach- 
contents,  133 
of  testing  for  lactic  acid,  150 
on  bacillus  coli  communis,  155 
on     lactic     fermentation     in     cancer    of 
stomach,  535 
Strauss's  apparatus,  73  91,  92 
Stricture  of  the  cardia,  308 
Strontium  bromid.     See  Broniid  of  stron- 
tium. 
Strophanthus  in   upward  displacement   of 

stomach,  557 
Strychnin  in  anorexia,  275 
in  flatulency,  253 
in  gastric  fermentation,  221 
in  gastroplegia,  335 
in  gastroptosis,  574 

with  chronic  colitis,  575 
in  habitual  regurgitation,  322 
in  hypersthenia  gastrica,  257 
in  myasthenia  with  stagnation,  363 
in  mycotic  gastritis,  3S6 
in  nervous  vomiting,  332 
in  pyloric  incontinence,  335 

obstruction,  606 
in  rumination,  325 
Subacidity,  301 
diet  in,  214 
hydrochloric,  117 
Subdiaphragmatic  abscess.   See  Subphrenic 

abscess. 
Subjective  symptoms,  35 
Subnitrate  of  bismuth  in  hypersthenic  gas- 
tritis, 42S 
in  ulcer  of  stomach,  504 
Subnutrition   as  a  cause  of  stomach   dis- 
ease, 638 
eflTect  of,  186 

from  disease  of  stomach,  617 
Subphrenic  abscess,  diagnosis  of,  491-495     • 
etiology,  495 

from  gastric  ulcer,  operation  in,  511 
gas  in,  490 

in  ulcer  of  stomach,  455,  4S8 
symptoms,  491 
Subsulphateof  iron  in  ulcer  of  stomach,  504 
Suction  method  of  removing  stomach-con- 
tents, 91 
Sugar,  concentrated  solutions  of,  211 
digestion  of,  iSi 
in  catarrhal  gastritis,  411 
-of-lead-cotton  method,  155 
Sulphate  of  anilin   in   cancer  of  stomach, 

551 
Sulphocyanid   of   ammonium,   decinormal 

solution  of,  113 
Sulphuric-acid  poisoning,  394 
Superacidity,  286 

hydrochloric,  286 
Supersecretion,  295 
Surgical  treatment  of  gastric  ulcer,  509 
Swallowing  of  air,  304 

method  of  introducing  the  stomach-tube, 
90 
Sweet-bread  in  catarrhal  gastritis,  412 

-oil  in  gastroptosis  with  chronic  colitis, 

575 
Sweets,  211 
in  adenasthenia,  303 
in  bulimia,  269 
in  catarrhal  gastritis,  412 
in  digestive  hyperchylia,  298 
in  gastric  fermentation,  216 
in  gastroptosis,  574 
in  hyperchlorhydria,  294 
in  myasthenia  with  retention,  375 

with  stagnation,  360 
in  obstruction  of  pylorus,  605 


672 


INDEX. 


Sweets  in  ulcer  of  stomach,  502 
Sympathetic  ganglia,  electric  excitation  of, 

243 
Symptomatic  gastrospasm,  314 

treatment,  251-253 

vomiting,  326 
Symptomatology.    See  various  diseases  in 

Sections  IV  and  V. 
Symptom-group,  22,  23 
Symptoms,  subjective  and  objective,  22 


Tabes  dorsalis,  gastric  crises  of,  640.  641 
gastrospasni  in,  314 
vomiting  111,426 
Tachycardia  from  disease  of  stomach,  621 
in  myasthenia  with  retention,  366 
in  neurasthenia  gastrica,  340 
Tannin  in  ulcer  of  slomach]^  504 
Tartaric  acid  as  an  antidote,  396 

in  inflation  of  stomach,  72 
Tea  in  adenasthenia,  303 
in  digestive  hyperchylia,  29S 
in  gastritis  glandularis  atrophicans.  442 
in  hyperchlorhydria,  294 
in  myasthenia  with  stagnation,  361 
in  obstruction  of  pylorus,  605 
Teeth,  condition  of,  54 
Temperament,  neurotic  or  nervous,  264 
Tender  points  in  the  differential  diagnosis 
of   ulcer    and    displacement    of    the 
stomach,  482 
in  ulcer  of  the  stomach,  469 
Tenderness,  57 
Terminal  It-ukopenia,  537 
Test-breakfast  in  pyloric  incontinence,  334 
obstruction,  604 
of  Ewald  and  Boas,  9s 
-dinner  in  pyloric  incontinence,  334 

of  Riegel,  97 
for  labferment,  121 
for  salicyluric  acid,  134 
-meals,  93 

in  pyloric  obstruction,  595 
normal  digestion  of,  94-98,  133,  296 
of  Bourget,94 
of  Germain  See.  96 
of  Jaworski,  94 
of  Klemperer,  94 
of  absorption.     Sev  Absorption, 
of  Boas  for  labferment,  121 
of  Fleischer,  135 
of  Korcynski  and  Jaworski,  159 
of  Leo,  121 

of  motor  function.     See  yfotor  futiclion. 
of  secretion.    See  Sfcreiion. 
Uffelmann's,  for  lactic  acid,  150 
Van  Deen's,  for  blood,  15S 
water-,  for  motor  insufficiency,  13S 
Weber's,  for  blood,  159 
Tetany  from  disease  of  the  stomach,  625 
ga.stric,625 

in  myasthenia  with  retention,  366 
Teufel,  bandage  of,  250 

Theories  concerning  the  secretion  of  hydro- 
chloric acid,  98 
of  nutrition,  169 
Theory  of  Hayem.98 
Thiersch's  solution   in  obstruction  of  car- 

dia,  583 
Thirst,  45 

Thomas  on  the  vomiting  center,  132 
Thoracic  diseases  as  a  cause  of  diaphrag- 
matic abscess,  495 
"  Three-layer  "  vomit,  29 
Throat,  diseases   of,   as  causes   of  gastric 

disease,  644 
Thrombosis,  vomiting  in,  326 


Tight  lacing  as  a  cause  of  displacements 

of  stomach,  566 
Toast  in  gastroptosiswith  neurasthenia,  576 
Tobacco  a  cause  of  cardiospasm,  304 
of  gastralgia,  276 
of  vomiting,  327 

-poisoning,  hyperchlorhydria  in,  287 
Tongue,  condition  of,  55 
Tonicity  of  the  stomach,  139 
Tonics  in  neurasthenia  gastrica,  346 
Topfer,  method  of,  106 
Tormina  ventriculi,  240 

nervosa,  315,  316 
Total  acidity,  106 
Toxemia,  vomiting  in,  326 
Toxic  gastritis,  acute,  391 

as  a  cause  of  pyloric  obstruction,  589 

symptoms  in  pyloric  obstruction.  593 
Toxins  from  stomach-contents,  628 
Traction  sensations,  36 
Transfusion  in  the  hemorrhage  of  gastric 

ulcer,  505 
Transposition  of  stomach,  554 
Traumatic  shock  a  cause  of  gastroplegia, 

335 
Traumatism,  163 

of  the  brain,  vomiting  in,  326 
Treatment,  bacteriological,  258,  259 

chemical,  259-261 

physiological,  253-25S 

symptomatic,  251 
Troparolin,  103,  104 
Trousseau  diet,  165 

on  gastric  vertigo,  625 
Trousseau's  sign,  627 
Tubercular  fever,  influence  of,  on  gastric 

secretion,  649 
Tuberculosis,  differentiation  of,  from  can- 
cer of  stomach,  548,  549 

pulmonary,  as  a  cause  of  stomach   dis- 
ease, 646-650 

vomiting  in,  649 
Tumor  in  cancer  of  stomach,  540 

in   diagnosis  of  cancer  of  stomach,  545, 
.546,  547 

in  ulcer  of  stomach,  470 

obstruction  of  pylorus  by,  585 

of  pylorus  in  pyloric  obstruction,  544 

of  the  stomach,  57 
benign  and  malignant,  544 
differentiation  of,  from  tumors  of  other 
organs.  541,  542.  543 

pyloric,  in  diagnosis  of  pyloric  obstruc- 
tion, 597 
Turck's  revolving  sponge.  64 
Ty|»hoid   fever   as  a  cause  of  myasthenia 

gastrica,  34S 
Tyrosin  in  the  stomach,  155 

Uffelman.n's  method   or    test   for  lactic 

acid,  150 
Ulcer  of  stomach.  412 

adhesion  from,  495 

anatomical  characteristics,  452-456 

anemia  in,  471-473 

as  a  cause  of  pyloric  incontinence.  333 
pyloric  obstruction,  585,  589 

bulimia  in,  266 

cardinal  symptoms,  459 

cicatrix  of,  455 

clinical  description,  456 

collapse  in,  505 

complicated  with  cancer,  485 
with  plastic  peritonitis,  485 

comiilications  of.  484    • 

condition  of  the  blood  in,  471 

constipation  in,  474 


INDEX. 


673 


Ulcer  of  stomach,  defoimity  from,  496 
diagnosis,  475 
diet  in,  500 

diflfereiitial  diagnosis  of,  477 
differentiation    of,   from    adenohyper- 
sthenia  gastrica,  478 

from  cancer,  479 

from  cholelithiasis,  482 

from  displacements,  481 

from  gastralgia,  279,  283,  284,  478 

from  hyperchlorhydria,  292 

from  neurasthenia  gastrica,  343 

from  spasm  of  stomach,  309 

from  ulcer  of  the  duodenum, «^83 

pulmonary  and   gastric  hemorrhage 
in, 467 
dorsal  tender  point  in,  469 
epigastric  tender  point  in,  469 
evolution  of,  458 
excision  of,  509 
expectant  treatment  of,  499 
favorite  localities  of,  452 
fistula  from,  496 
forced  feeding  in,  187 
formation  and  development  of.  457 
frequency  of,  443 
functional  signs  of,  473 
healing  of,  474 
hematemesis  in,  463 
hemorrhage  in,  463 
immobilization  in  treatment  of,  499 
inanition  anemia  in,  472 
influence  of  age  on,  446 

of  diet  on,  447 

of  disease  of  blood  on,  448 

of  diseases  of  heart  and  blood-vessels 
on,  448 

of  hydrochloric  superacidity  on,  449 

of  occupation  on,  447 

of  sex  on,  446 

of  temperature  of  food  on,  500 
insufficient  diet  in,  1S6 
melena  in,  466 
mortality  from,  474,  497 
nutrition  in,  470 
objective  signs  of,  46S 
oligocythemia  in,  471 
pain  of,  4,s9 

pathological  anatomy,  451 
perforation  in,  454,  486 

treatment  of,  508 
prognosis,  497 

rectal  feeding  in,  221,  500,  501,  507 
rest  and  Carlsbad  cure  of,  506 

and  rectal  feeding  cure  in,  507 

in,  164 
sequelae  of,  495 
shape  of,  452 
size  of,  452 

spasm  of  pylorus  in,  311 
surgical  treatment  of,  509 
table  of   deaths   from,   in    New    York 

City,  445 
tender  points  in,  469 
terminations  of,  474 
treatment,  498-511 

of  vomiting  in,  505 
tumor  in,  470 
vomiting  in,  462 

of  blood  in,  463 
walking  treatment  in,  500 
with      ulceration    of    adjacent     parts, 

487 
Ulcus    duodeni,    differentiation    of,    from 

ulcer  of  stomach,  483 
Umbilicus,  49 

Uncomfortable  sensations,  38 
Units  of  heat,  173-175 

44 


Upward     displacement    of    stomach.     See 

Displacement  of  stomach,  nptvard. 
Uremia  as  a  cause  of  neurasthenia  gastrica, 
338 

as  a  cause  of  stomach  disease,  639 
Uric  acid  diathesis,  619 

elimination  in  cancer  of  stomach,  538 
excess  of,  from  disease  of  stomach.  619 
formation  in  gastroptosis,  567 
Uricemia  as  a  cause  of  neurasthenia  gas- 
trica, 338 

from  disease  of  stomach,  617 

in  gastroptosis,  568 

water  in,  227 
Urine,  acidity  of,  620 

as  a  measure  of  degree  of  gastric  reten- 
tion, 604 

drinking  of,  271 

examination  of,  in  neurasthenia  gastrica, 
342 

excess  of  uric  acid  in.  619 

in  adenasthenia  gastrica,  301 

in  asthenic  gastritis,  408 

in  cancer  of  stomach,  538 

in  gastralgia,  277 

in  hyperchlorhydria,  291 

in  hypersthenic  gastritis,  422 

in  myasthenia  with  retention,  366 
with  stagnation,  352 

influence  of  disease  of  stomach  on,  630 

phosphates  in,  620 

toxicity  of,  in  diseases  of  stomach,  611 
Urobilin  in  urine  of  cancer  of  stomach,  538 
Urticaria  in  myasthenia  with  retention,  366 

in  pyloric  obstruction,  592 

from  disease  of  stomach,  630 


Vagosympathetic  irritation,  relief  of,  250 

nerve,  47 
excitation  of,  242 
Vagus,  irritation  of,  323 
Valentine's  meat  juice,  196 
Valerian  in  nervous  vomiting,  332 
Valleix   on  influence  of  sex   in   cancer  of 

stomach,  514 
Valvular  disease  as  a  cause  of  disease  of 

stomach,  635 
Van  Deen's  test  for  blood,  158  , 

Van  Valzah  and  Nisbet,  method  of,  140 
Vanillin,  103 

Varicose  esophageal  veins,  309 
Vascular  disorders  in  pyloric  obstruction, 

593 
Vegetable  albumin,  209 

calorimetric  value  of,  175 
Vegetables,  211 

in  adenasthenia,  303 

in  bulimia,  269 

in  digestive  hyperchylia,  299 

in  gastric  fermentation,  216 

in  gastroptosis,  574 
with  neurasthenia,  576 

in  hyperchlorhydria,  294 

in  hypersthenic  gastritis,  427 

in  myasthenia  with  stagnation,  361 

in  neurasthenia  gastrica,  346 

in  obstruction  of  pylorus,  605,  607 

in  ulcer  of  stomach,  502 
Venison,  195 
Veratrum  viride,  255 
Vertical   displacement    of   stomach.      See 

Displacement  of  stomach,  vertical. 
Vertigo  a  stomacho  laeso,  625 

gastric,  625 
Vicious  circles  of  the  stomach,  610 
"  Vigor  chocolate,"  217,  361 
in  catarrhal  gastritis,  412 


6/4 


INDEX. 


'■  Vigor  chocolate  "  in  gastritis  glandularis 
atrophicans,  442 
in  hyperchlorhydria,  294 
in  hypersthenic  gastritis,  426 

Vinegar  as  an  antidote  to  caustic  alkalies, 

effect  of,  in  gastroptosis,  567 
Virchow  on  influence  of  diseases  of  blood- 
vessels on  ulcer  of  stomach,  44S 

on  mortality  from  cancer  of  stomach.  513 
Visible  peristalsis,  315 
Voice,  use  of.  after  raeals,  164 
Vol  hard,  method  of,  112 
Vomit  in  catarrhal  gastritis,  405 

in  hypersthenic  gastritis,  422 

■■  three-layer,"  29 
Vomiting.  44 

as  a  diflferential  sign  between  pyloric  and 
duodenal  obstruction,  601 

as  a  means  of  obtaining  the  stomach- 
contents.  S3 

center,  32.S 

central,  326 

cerebral,  641 

diagnosis  of  the  varieties  of,  330 

fecal,  in  fistula  from  gastric  ulcer,  496 

from  disease  of  intestines,  632 

from  hysteria.  643 

from  pneumonia.  645 

hematogenous,  227 

hysterical.  327 

in  cancer  of  stomach,  524 

in  cardiospasm.  306 

in  digestive  hyperchylia  gastrica,  295 

in  excessive  peristalsis,  316 

in  gastroptosis,  567 

in  locomotor  ataxia,  640 

in  meningitis,  6ji 

in  myasthenia  with  retention,  365 

in  obstruction  of  cardia,  5S0 
pylorus,  5S^S,  5S9 

in  paroxysmal  hyperchylia,  299 

in  perforation  of  stomach  from  ulcer,  487 

in  pyloric  obstruction,  591 

in  spasm  of  the  pylorus,  312 

in  subphrenic  abscess  from  ulcer  of  stom- 
ach, 492 

in  tuberculosis,  649 

in  ulper  of  stomach,  462 
treatment  of,  505 

nervous.  325,  327 

of  blood  in  ulcer  of  stomach,  463 

periodical,  329 

psychic,  32S 

reflex,  327 

remedies  for,  252,  253 

symptomatic,  326 
treatment  of,  253 

treatment  of,  331 
Von  Ziemssen  method  of  galvanization,  242 
on  rest  and  Carlsbad  cure,  506.  507 


VValdever  on  ulcer  of  stomach,  443 
Walking  treatment  of  ulcer  of  stomach,  500 


Warm  water  in  eructatio  nervosa,  321 
Water,  action  of.  on  stomach,  227 
external  use  of,  235 
insufficiency,  227 
-test,  292 

for  motor  insufficiency,  139 

in  diagnosis  of  myasthenia  gastrica,  354 

in  differentiation  between  benign  and 

malignant  pyloric  obstructions,  603 

between    myasthenia   and   digestive 

hyperchylia  gastrica,  297 
between      myasthenia     and     hyper- 
sthenic gastritis  with  supersecre- 
tion,  422 
between  myasthenia  and  pyloric  ob- 
struction; 358.  373.  595,  599 
use  of,  in  treating  stomach  diseases,  227- 
258 
Weakness  in  gastroptosis,  56S 
Weber's  test  (or  blood,  158 
Wegele's  spiral  electrode,  238,  239 
Weight  as  a  guide  to  dietetic  treatment, 

224 
Weir  ana  Foote  on  operations  for  perforat- 
ing nicer  of  stomach,  510 
on  perforation  in  ulcer  of  stomach,  486 
Welch  on   localities  of  ulcer  of  stomach, 

452 
Wheaten  grits,  208 

White  blood-corpuscles  in  cancer  of  stom- 
ach, 537 
influence  of  disease  of  stomach  on,  616 
of  egg,  206 
as  an  antidote,  396 
test-meal  of  Jaworski,  94 
Widal  serum  sign  in  gastric  fever.  391 
Wilkinson  on  congenital  cancer  of  stom- 
ach. 513 
Williams  on  cure  of  grastric  ulcer,  507 
Willigk  on  ulcer  of  stomach,  446 
Wine,  effect  of.  in  gastroptosis,  567 
in  gastroptosis  with  chronic  colitis,  576 
in  pyloric  obstruction,  605 
Winter,  method  of  Hayem  and,  iii 
Winternitz.  236 
compress  of,  253,  284 
in  hyperchylia.  300 
in  hypersthenic  gastritis.  429 
in  pyloric  obstruction,  607 
in  spasm  of  the  pylorus,  313 
in  the  vomiting  of  gastric  ulcer,  506 
Wirderhofer  on  congenital  cancer  ofstom- 

ach.  513 
Worry  as  a  cause  of    neurasthenia  gas- 
trica, 33S 


Yeast,  145 
fermentation,  154 


Zabludowski,  method  of,  247.  248 

Zuntz  on  consumption  of  oxygen   by  the 

body,  174,  175 
Zymogenic  bacteria.  147 


CATALOGUE 

OF   THE 

MEDICAL  PUBLICATIONS 

OF 

W.  B*  SAUNDERS, 

No.   925   WALNUT   STREET,   PHILADELPHIA. 


Arranged  Alphabetically  and  Classified  under  Subjects. 


'  I  "^riE  books  advertised  in  this  Catalogue  as  being  sold  by  subscription  are  usually  to  be 
obtained  from  traveling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.  All  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States ; 
but  any  book  will  be  sent  by  the  publisher  to  any  address,  carriage  prepaid,  on  receipt  of 
the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways : 
A  post-office  money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered 
letter.    Money  sent  in  any  other  way  is  at  the  risk  of  the  sender. 


See  pages  30,  31,  for  a  List  of  Contents  classified  according  to  subjects. 


LATEST  PUBLICATIONS. 


Amer .Text-Book  of  Genito-Urinary  and  Skin  Diseases.  Page  4. 

Macdonald^s  Surgical  Diagnosis,  just  Ready.  See  page  I6. 

Anders^  Practice  of  Medicine — Revised  Edition.   See  page  6. 

Moore^s  Orthopedic  Surgery,  just  Ready.   Sec  page  J7. 

Penrose^s  Diseases  of  Women.   See  page  I8. 

Mallory  and  Wright^s  Pathological  Technique.   See  page  I6. 

Van  Valzah  and  Nisbet^s  Diseases  of  the  Stomach.   See  page  28. 

American  Year-Book  of  Medicine  and  Surgery.   See  page  6. 

Sennas  Genito-Urinary  Tuberculosis.  See  page  25. 

Sutton  and  Giles^  Diseases  of  Women.  See  page  28. 

Stoney^s  Nursing — Revised  Edition.   See  page  27. 

Garrigues^  Diseases  of  Women — Revised  Edition.  See  page  n. 

Keen^s  Surgical  Complications  of  Typhoid  Fever.  See  page  I5. 

Gould  and  Pyle^s  Curiosities  of  Medicine.   See  page  u. 

De  Schweinitz^  Diseases  of  the  Eye — Revised  Edition.   Page  JO. 

Chapin^s  Compendium  of  Insanity,  just  Ready.   See  page  8. 

Church  and  Peterson^s  Nervous  and  Mental  Diseases.   Page  9. 

Saunders^  Medical  Hand-Atlases.   See  page  2. 

DaCosta^s  Surgery — Revised  and  Enlarged  Edition.    See  page  jo. 


SPEOAL  ANNOUNCEMENT. 


Mr.  Saunders  is  pleased  to  announce  that  arrangements  have  been  completed  for  the 
publication  of  an  English  edition  of  the  world-famous 

Lehmann  medicinische  Handatlanten. 

For  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheapness  these  books 
surpass  any  similar  volumes  ever  published.      Each  volume  contains  from 

50  to  100  Colored  Plates, 

besides  numerous  other  illustrations  in  the  text.  These  colored  plates  have  been  executed 
"by  the  most  skilful  German  lithographers,  in  some  cases  twenty  or  more  impressions  being 
required  to  obtain  the  desired  result.  There  is  a  full  and  appropriate  description  of  each 
plate  (printed,  for  convenience,  opposite  the  plate),  together  with  a  condensed  outline  of 
the  subject  to  which  the  book  is  devoted. 

The  same  careful  and  competent  editorial  supervision  will  be  secured  in  the 
English  edition  as  in  the  originals.  The  translations  will  be  directed  and  edited  by  the 
leading  American  specialists  in  the  different  sut)jects. 

The  great  advantage  of  natural  pictorial  representation  is  indisputable.  For  lasting  and 
practical  knowledge,  one  accurate  illustration  is  better  than  several  pages  of  dry 
description. 

These  Atlases  offer  a  ready  and  satisfactory  substitute  for  clinical  observation,  avail- 
able only  to  the  residents  of  large  medical  centers ;  and  with  such  persons  the  requisite 
variety  is  seen  only  after  long  years  of  routine  hospftal  service. 

By  reason  of  their  projected  universal  translation  and  reproduction,  affording  inter- 
national distribution,  the  publishers  have  been  enabled  to  secure  for  these  Atlases  the  best 
artistic  and  professional  talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to 
offer  them  at  a  price  heretofore  unapproached  in  cheapness.  The  success  of  the  under- 
taking is  demonstrated  by  the  fact  that  volumes  have  already  appeared  in  German,  English, 
French,  Italian,  Russian,  Spanish,  Danish,  Swedish,  and  Hungarian. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has  heretofore  been 
practically  debarred  from  purchasing  similar  works  because  of  their  extremely  high  price, 
made  necessary  by  the  limited  sale  and  the  enormous  expense  of  production.  The  very 
low  price  of  these  Atlases  will  place  them  within  the  reach  of  even  the  novice  in  practice. 

NOW  READY. 

Atlas  of  Internal  iVledicine  and  Clinical  Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlaiigen.  Edited 
by  .-XuGi-STrs  A.  KsHNKK,  M.D.,  ProrcssorolCliiiical  Medicine  in  the  Philadelphia  Polyclinic;  At- 
tending Physician  to  the  Philadelphia  Hospital.  68  colored  plates,  and  64  illustrations  in  the  text. 
Cloth,  I3.00  net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.D..  Cliniial  Professor  of  Mental  DiseasL-s,  Woman's  .Medical  College,  New  York;  Chief 
of  Clinic,  Nervous  Dept.,  College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  fig- 
ures on  56  plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  I3.50  net. 

Atlas  of  Diseases  of  the  Larynx.     By   Dk.    L.  Grl'swaid,  of   Munich.     Edited  by  Charles  P. 

Grayson,  M.D.,  Lecturer  on  Laryngology  and  Rliinology  in  the  I'niversity  of  Pennsylvania; 
Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  and  25  text-illustrations.     Cloth,  J2.50  net. 

IN  PREPARATION. 

Atlas  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl.  of  Vienna.  Edited  by  J.  Chal.mers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia;  Surgeon 
to  the  Philadelphia  Hospital.     With  24  colored  plates,  and  217  illustrations  in  the  text. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  Franz  MRACEK.of  Vienna.  Edited 
bv  L.  Bolton  Bangs,  NLD.,  late  Professor  of  Genito-Urinary  and  Venereal  Diseases,  New  York 
Piist-Graduate  Medical  School  and  Hos|>ital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations. 

Atlas  of  External  Diseases  of  the  Eye.  Bv  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E. 
DE  ScHWKiNiTZ,  M.D.,  Professor  of  Ophthalmology-,  Jefl^erson  Medical  College,  Philadelphia. 
Willi  100  colored  illustrations. 

Atlas  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  With  80  colored  plates  from 
original  water-colors. 


«a 


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By  63  Eminent  Contributors.  Edited  by  Louis  Starr,  M.D.,  Physi- 
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AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
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By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schv^einitz,  M.D., 
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Affections  of  the  Skin. 

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undertaking,  the  Editors  have  not  restricted  the  Contributors  in  regard  to  the  particular  views  set 
forth,  but  have  offered  every  facility  for  the  free  expression  of  their  individual  opinions.  The  work 
will  therefore  be  found  to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
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AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
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illustrations  in  the  text,  and  37  colored  and  half-tone  plates.  Cloth, 
$6.00  net;  Sheepor  Half  Morocco,  $7. 00  net.     Sold  by  Subscription. 

"  It  is  practical  from  beginning  to  end.  Its  descriptions  of  conditions,  its  recommen- 
dations for  treatment,  and  above  all  the  necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.  .  .  .  It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.  It  is  destined 
to  make  and  hold  a  place  in  gynecological  literature  which  will  be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.     ///  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
Ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  over  1000  pages,  with  nearly  900  beautiful 
colored  and  half-tone  illustrations.  Cloth.  $7. 00  net;  Sheep  or  Half 
Morocco,  58.00  net.     Sold  by  Subscription. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." — Alexander 
J.  C.  Skene,  Professor  of  Gynecology  in  (he  Long  Island  College  Hospital,  Brooklyn,  N.  Y. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  In 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Medical  Journal. 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 
titioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Sciences. 

Illustrated  Catalogue  of  the  "American  Text-Books  "  sent  free  upon  application. 


Medical  Publications  of  W,  B.  Saunders.  5 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and 
of  Morbid  Anatomy  in  the  University  of  Pennsylvania ;  and  David 
RiESMAN,  M.D. ,  Demonstrator  of  Pathological  Histology  in  the 
University  of  Pennsylvania.     In  Preparatio7i. 

AN  AMERICAN  TEXT=BOOK  OF  PHYSIOLOGY. 

By  I  o  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  One  handsome  imperial  octavo 
volume  of  1052  pages.  Illustrated.  Cloth,  $6. 00  net ;  Sheep  or  Half 
Morocco,  $7.00  net.     Sold  by  Subscription. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — Lotidon  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journat  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  SURGERY.     Second  Edition. 

By  13  Eminent  Professors  of  Surgery.  Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  and  J.  William  White,  M.D.,  Ph.D.  Handsome 
imperial  octavo  volume  of  1250  pages,  with  500  wood-cuts  in  the  text, 
and  39  colored  and  half-tone  plates.  Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.  So  id  by  Sub- 
scription. 

"  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book),  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F. R.C.S.,  Member  of 
the  Board  of  Exatniners  of  the  Royal  College  of  Surgeons,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  LTniversity  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
^6.00  net.     Sold  by  Subscriptiofi. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Practice  of  Aledicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess. '  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see. " — New  York  Medical 
Journal. 

Illustrated  Catalogue  of  the  "American  Text-Books'*  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders. 


AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and 
general  make-up  with  the  "American  Text-Book"  Series.  Cloth, 
$6.50  net;  Half  Morocco,  $7.50  net,     So/(/  by  Subscription. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Vear-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  .  .  .  It  is  much  more  than  a  mere  compilation  of  abstracts, 
for,  as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the 
advantage  of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers 
fully  qualified  to  perform  these  tasks.  .     .     It  is  emphatically  a  book  which  should  find 

a  place  in  every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous 
'  Jahrbiicher '  of  Germany." — London  Lancet. 

ANDERS'  PRACTICE  OF  MEDICINE.    Second  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1287  pages,  fully  illustrated.  Cloth, 
$5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson 
Medical  College,  Philadelphia. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by 
far  the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up 
to  date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher." — 
A.  C.  Cowi'ERTHWAlTE,  President  of  the  Lllinois  Homeopathic  Medical  Association. 

ASHTON'S  OBSTETRICS.     Third  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages;  75  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders'  Question- Comfends,  page  21.] 

"  Embodies  the  whole  subject  in  a  nut-shell.  We  cordially  recommend  it  to  our  read- 
ers."— Chicago  Medical  Times. 

BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  j^lates.  Cloth,  $1.00; 
interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders.  7 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.A., 
late  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  ^2.50. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alii7)ini  Repoi-t  to  the  Philadelphia  College  of  Pharmacy . 

"There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country, 
and  we  predict  for  it  a  wide  circulation." — America^i  Joiirtial  of  Pharmaey. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;   65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"  An  excellent  exposition  of  the  '  very  latest '  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Birmingham  (Eng.)  Medical  Review. 

"This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

BoisLiNiERE,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.    381  pages,  handsomely  illustrated.    Cloth,  ^2.00  net. 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience." — British  Aledical Journal. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Aledical  Jouriial. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages  ;   155  fine  illustrations. 
Cloth,  gi.oo  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  21.] 

"  The  student  who  is  well  versed  in  these  pages  will  certainly  prove  qualified  to  com- 
prehend with  ease  and  pleasure  the  great  majority  of  questions  involving  physical  principles 
likely  to  be  met  with  in  his  medical  studies." — American  Practitioner  and  News. 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — JVetu  York  Medical  Journal. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously 
illustrated." — Medical  Record,   New  York. 

BURR  ON  NERVOUS  DISEASES. 

A  Manual  of  Nervous  Diseases.  By  Charles  W,  Burr,  M.D., 
Clinical  Professor  of  Nervous  Diseases,  Medico-Chirurgical  College, 
Philadelphia ;  Pathologist  to  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases;  Visiting  Physician  to  St.  Joseph's  Hospital,  etc. 
^n  Preparation. 


8  Medical  Publications  of  W.  B.  Saunders. 


BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. 
A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Pw.Ci.,  iVLD.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago  ;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  858 
pages,  illustrated.     Cloth,  ^4.00  net ;    Sheep,  $5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  l>e  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market  " — Journal  0/  the  American 
Metrical  .Assoiiiition. 

"  The  work  is  executed  in  a  clear,  concise,  and  practical  manner,  and  should  meet  with 
a  hearty  endorsement  from  the  students  of  our  up-to-date  colleges.  The  book  will  be  found 
a  valuable  work  of  reference  for  the  practitioner." — American  Medico-Surgical  Bulletin. 

CASSELBERRY  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  W.  E.  Casselberrv,  Pro- 
fessor of  Laryngology  and  Rhinology  in  the  Northwestern  University 
Medical  School,  Chicago.     In  Preparation. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.     By  David  Cerna,  M.D.,  Ph.D., 

formerly  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  L'niversity  of  Te.xas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  $1.25. 

'•These  '  Notes '  will  be  found  ven,-  useful  to  practitioners  who  take  an  interest  in  the 
many  newer  remedies  of  the  present  day.' — Edinburgh  Medical  Journal. 

"  The  appearance  of  this  new  edition  of  Dr.  Cerna's  ven,'  valuable  work  .shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— New  York  Aledical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  ^LD.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Societv  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium.     Cloth,  §1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of  Diseases  of 
the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students.  The  work  will  also 
prove  valuable  to  members  of  the  legal  profession  and  to  those  who,  in  their  relations  to  the 
insane  and  to  those  supposed  to  be  insane,  often  desire  to  acquire  some  practical  knowledge 
of  insanity  presented  iu  a  form  that  may  be  understood  by  the  nonprofessional  reader. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  gf  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  §1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of" — A'ew  York 
Medical  Times. 


Medical  Publications  of  W.  B.  Saunders.  9 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 
Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.D., 
Professor  of  Mental  Diseases  and  Medical  Jurisprudence  in  the  North- 
western University  Medical  School,  Chicago  ;  and  Frederick  Peter- 
son, M.D.,  Clinical  Professor  of  Mental  Dis^^ases  in  the  Woman's 
Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.     In  Preparatio7i. 

CLARKSON'S  HISTOLOGY. 

A  Text=Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  CM.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $6.00  net. 

"The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books, 
and  is  to  be  highly  recommended." — New  York  Medical  Journal. 

"This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

"The  volume  is  a  most  valuable  addition  to  the  armamentarium  of  the  teacher." — 
Brooklyn  Medical  Journal. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1891.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS. 

Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic;  and  Augustus  A.  Eshner,  M.D.,  Instructor  in  Clinical 
Medicine,  Jefferson  Medical  College,  Philadelphia.  Post-octavo,  382 
pages;   55  illustrations.      Cloth,  $1.50  net. 

[See  Saunders'  Question- Competids,  page  21.] 

"We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  CoRwiN,  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    200  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis." — Journal  of  Nervotis  and  Mental  Diseases. 


10  Medical  Publications  of  W.  B.  Saunders. 

CRAQIN'S  GYN/ECOLOQY.     Fourth  Edition,  Revised. 

Essentials  of  Gynsecology.  By  Edwin  B.  Cragin,  M.D.,  Attend- 
ing Ciynjecologist,  Roosevelt  Hospital,  Out-Patients'  Department,  New 
York,  etc.  Crown  octavo,  200  pages;  62  fine  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  §1.25. 

[See  Saunders^  Question- Compemh,  page  21.] 

"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.  No 
author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student's  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  York. 

CROOKSHANK'S  BACTERIOLOGY. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.B.^ 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  $6.50  net;  Half  Morocco,  $7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resiifne  of  what  has  been  done  in  bacteri- 
ology, or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — London  Lancet. 

DaCOSTA'S  SURGERY. 

A    Manual    of    Surgery,    General    and    Operative.     By  John 

Chalmers  DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson 
Medical  College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital, 
etc.  Handsome  volume  of  810  pages;  1S8  illustrations  in  the  text, 
and  13  full-page  plates.     New  and  Enlarged  Edition  in  Preparation. 

"We  know  of  no  small  work  on  sui^ery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modem  student." — Medico-Chirurgical Journal,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.     Second  Edition^ 
Revised. 
Diseases  of   the  Eye.     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  DE  ScHWEiNiTZ,  ^LD.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  679  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  §4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  sp>ecial  l)ranch  of  medical  science." — British  Medical  Journal. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper,  M.D..  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine ^ 
Universily  of  Pennsykania. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A,  Newman  Borland,  M.D., 
.'\ssistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania ; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.     Cloth,  $2.50  net. 

"  By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medical  Pei'iew. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
j)erusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts.  ' — American  Medico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders.  11 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
INGHAM,  M.D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

"It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Ameri- 
can Medico- Surgical  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Second  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro- 
fessor of  Gynecology  and  Obstetrics  in  the  New  York  School  of 
Clinical  Medicine;  Gynecologist  to  St.  Mark's  Hospital  and  to  the 
German  Dispensary,  New  York  City,  etc.  Handsome  octavo  volume 
of  728  pages,  illustrated  by  335  engravings  and  colored  plates.  Cloth, 
$4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.B., 
M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with 
114  illustrations.  Cloth,  $1.00;  interleaved  for  notes,  $1.  25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. ' ' — Liverpool  Medico-  Chii-urgical  Joiirnal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates.  Cloth,  ^6.00  net;  Half  Morocco,  $7.00  net. 
Sold  by  Subscription. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value :  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its  readers." — American  Medico- Surgical  Bulletin. 


12  Medical  Publications  of  W.  B.  Saunders. 


GRIFFIN'S  MATERIA  MEDICA  AND  THERAPEUTICS. 

Manual  of  Materia  Medica  and  Therapeutics.  By  Henry  A. 
Gkikmn,  A.B.,  M.D.,  Assistant  rhy.-ician  to  the  Roosevelt  Hospital, 
Out-Patient  Department,  New  York  City.      ///  Preparation. 

GRIFFITH  ON  THE  BABY. 

The  Care  of  the  Bahy.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal I'rofessor  of  Diseases  of  Children,  University  of  Pennsylvania ; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  i2nio,  392 
pages,  with  67  illustrations  in  the  text,  and  5  plates.      Cloth,  $1.50. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage. ' ' — Archives  0/  Pidiatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  obser^■ing  children." — Ameri- 
can Journal  of  Obstetj'ics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D.  , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first  two  years 
of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight  of  a  healthy  infant, 
so  that  any  deviation  from  the  normal  can  readily  be  detected. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D,  Gross,  M.D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Grcss,  M.D.,  LL.D.,  late  Professor  of  Principles  of  Sur- 
gery and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and 
A.  Haller  Gross,  A.M.,  of  the  Philadelphia  Bar.  Preceded  by  a 
Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D.,  LL.D.  In 
two  handsome  volumes,  each  containing  over  400  pages,  demy  octavo, 
extra  cloth,  gilt  tops,  with  fine  Frontispiece  engraved  on  steel.  Price 
per  volume,  §2.50  net. 

"X)r.  Gross  was  perhaps  the  most  eminent  exponent  of  medical  science  that  America 
has  yet  produced.  Ilis  Autobiography,  related  as  it  is  with  a  fulness  and  completeness 
seldom  to  be  found  in  such  works,  is  an  interesting  and  valual)le  book.  He  comments  on 
many  things,  especially,  of  course,  on  medical  men  and  medical  practice,  in  a  very  interest- 
ing way." — 77/1?  Spectator,  London,  England. 

HAMPTON'S  NURSING. 

Nursing:  Its  Principles  and  Practice.  By  Isabel  Adams  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  Superintendent  of  Nurses,  and  Principal  of  the 
Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md. 
i2mo,  484  pages,  profusely  illustrated.     Cloth,  $2.00  net. 

"  .Seldom  have  we  perused  a  book  upon  the  subject  that  has  given  us  so  much  pleasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self." —  Ontario  Medical  Journal. 


Medical  Publications  of  W.  B.  Saunders.  13 

HARE'S  PHYSIOLOQY.     Third  Edition,  Revised. 

Essentials  of  Phiysiology.  By  H.  A.  Hare,  M.D.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia;  Physician  to  the  Jefferson  Medical  College  Hospital. 
Containing  a  series  of  handsome  illustrations  from  the  celebrated 
"  Icones  Nervorum  Capitis"  of  Arnold.  Crown  octavo,  239  pages. 
Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  21.] 

"The  best  condensation  of  physiological  knowledge  we  have  yet  seen." — Aledical 
Record,  New  York. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.  220  pages;  illustrated.  Cloth, 
^1.50. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — Nezv  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  ^2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.      The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
In  Preparation. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  In  Prepa- 
ration. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  III.  618  pages,  profusely  illustrated. 
Cloth,  $2.50  net. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
diseases. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Louis  Medical 
and  Surgical  Journal. 


14  Medical  Publications  of  W.  B.  Saunders. 


JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win GllasON,  M.D.  ,  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1-25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATINQ'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  Bv  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Pasdiatric  Society;  Editor 
"Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and  Henry 
Hamilton,  Author  of  '-'A  New  Translation  of  Virgil's  ./^neid  into 
English  Rhyme,"  etc.;  with  the  collaboration  of  J.  Chalmers  Da- 
Costa,  M.D..  and  Frederick  A.  Packard,  M.D.  With  an  Appendix 
containing  Tables  of  Bacilli,  Micrococci,  Leucomaines,  Ptomaines; 
Drugs  and  Materials  used  in  Antiseptic  Surgery;  Poisons  and  their 
Antidotes ;  Weights  and  Measures ;  Thermometric  Scales ;  New 
Official  and  Unofficial  Drugs,  etc.  One  volume  of  over  800  pages. 
Prices,  with  Denison's  Patent  Ready-Reference  Index:  Cloth,  $5. 00 
net;  Sheep  or  Half  Morocco,  §6.00  net;  Half  Russia,  §6.50  net. 
Without  Patent  Index:  Cloth,  54. 00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lyman,  M.D.,  Professor  of  the  Principles  and  Practice 
of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient 
in  size  and  sufficiently  full  for  ordinary'  use." — C.  A.  Lindsi.ey,  M.D.,  Professor  of  the 
Theory  and  Practice  of  Medicine,  Medical  Dept.   Yale  University. 

KEATINQ'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Pediatric  Society  ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination, 
a  subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume 
is  Part  II,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  If  for  these  alone,  the  book  should  be  at  the  right 
hand  of  every  physician  interested  in  this  special  branch  of  medical  science." — The  Medical 
News. 


Medical  Publications  of  W.  B.  Saunders.  15 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The   Surgical   Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Societe  de  Chirurgie,  Paris  ;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
about  400  pages.     Cloth,  ^^3.00  net. 

This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject  of  the 
Surgical  Comphcations  and  Sequels  of  Typhoid  Fever.  It  will  prove  to  be  of  importance 
and  interest  not  only  to  the  general  surgeon  and  physician,  but  also  to  many  specialists — laryn- 
gologists,   gynecologists,  pathologists,  and  bacteriologists. 

KEEN'S  OPERATION  BLANK.  Second  Edition,  Revised  Form. 
An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required 
in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.  Price  per  pad,  containing  blanks  for  fifty  operations, 
50  cents  net. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadelphia 
Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8  x  i^y^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid." — Indian  Lancet,  Calcutta. 

lockwood's  practice  of  medicine. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
wood,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.      Cloth,  $2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "  An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  M.D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  ^i.oo  net. 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Medical Jourtial. 


16  Medical  Publications  of  W.  B.  Saunders. 


MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  L.R.C.S.,  Kdin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco^ 
$6.00  net. 

"  The  rapid  advances  made  in  the  art  of  surgery  have  caused  the  literature  of  the  science 
to  grow  apace.  Systems  of  surgery  in  many  volumes,  and  text-books  of  large  dimensions, 
are  now  deemed  necessary  to  cover  the  field.  The  practical  j)art  of  the  surgeon's  work  is, 
however,  almost  limited  to  two  questions  which  he  must  answer  every  time  his  professional 
advice  or  help  is  sought.  The  first  question  is,  'What  is  the  disease  or  injury?'  The 
second  question  is,  '  What  is  the  proper  treatment  ?  ' 

"While  I  would  not  for  a  moment  underestimate  the  importance  of  a  profound  study 
of  the  principles  of  surgery,  of  surgical  pathology,  or  of  bacteriology,  the  present  work  will 
be  confined  to  a  solution  of  the  two  questions  just  mentioned,  with  the  view  of  putting  into 
the  hands  of  students  and  practitioners  a  single  volume  containing  the  most  practical  part 
of  practical  surgery." — From  the  Author'' s  Preface. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  By  Frank  B.  Mallorv,  A.jNI.,  M.D., 
Assistant  Professor  of  Pathology,  Harvard  University  Medical  School ; 
and  James  H.  Wright,  A.M.,  M.D.,  Instructor  in  Pathology,  Harvard 
University  Medical  School.  Octavo  volume  of  396  pages,  handsomely 
illustrated.     Cloth,  $2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date." — WiLLiAM  H.  Welch,  Professor  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Aid. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown 
octavo,  166  pages,  with  78  illustrations.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Sixth  Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown  octavo,  338 
pages,  illustrated.  With  an  Api^endix  containing  full  directions  for  the 
preparation  of  the  materials  used  in  Antiseptic  Surgery,  etc.  Cloth, 
§1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  Contains  all  necessary  essentials  of  modem  surgery  in  a  comparatively  small  space. 
Its  style  is  interesting,  and  its  illustrations  are  admirable." — Medical  and  Surgical  Peporter^  - 


Medical  Publications  of  W.  B,  Saunders.  17 

MCFARLAND'S  PATHOGENIC  BACTERIA. 

Text=Book  upon  the  Pathogenic  Bacteria.  Specially  written 
for  Students  of  Medicine.  By  Joseph  McFarland,  M.D.,  Pro- 
fessor of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  College 
of  Philadelphia,  etc.  Octavo  volume  of  359  pages,  finely  illustrated. 
Cloth,  $2.50  net. 

"  Dr.  McFarland  has  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto- 
gether, the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College." — H.  B.  Anderson,  M.D.  ,  Professor  of  Pathology  and  Bac- 
teriology, Trinity  Medical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 
Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octava 
volume  of  356  pages,  handsomely  illustrated.      Cloth,  ^2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress  is  laid 
upon  early  diagnosis,  and  treatment  such  as  can  be  carried  out  by  the  general  practitioner. 
The  teachings  of  the  author  are  in  accordance  with  his  belief  that  true  conservatism  is  to 
be  found  in  the  middle  course  between  the  surgeon  who  operates  too  frequently  and  the 
orthopedist  who  seldom  operates. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fourth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription= 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia;  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  250  pages.  Cloth, 
;^i.oo;   interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Co7npends,  page  21.] 

"This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi- 
sion."— American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.  D., 
late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulae  collected  and  arranged  by  William  M.  Powell,  M.D- 
Post-octavo,  488  pages.      Cloth,  $2.00. 

[See  Saunders''   Question- Compends ,  page   21.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  and 
style  attractive." — American  Practitioner  and  News. 


18  Medical  Publications  of  W.  B,  Saunders, 


MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
■"How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.     Cloth,  $100. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
'of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Review. 

NANCREDE'S  ANATOMY.     Fifth  Edition. 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  H.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clini- 
cal Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown  octa\  o, 
388  pages;  180  illustrations.  With  an  Appendix  containing  over  60 
illustrations  of  the  osteology  of  the  human  body.  Based  upon  Gray  s 
Anatomy.  Cloth,  Si. 00;  interleaved  for  notes,  $1.25. 
[See  SaunJers'  Question- Conpends,  page  21.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — Avwricati  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of    Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo ;  500  pages, 
with  full-page  lithographic  plates  in  colors,  and  nearly  200  illustrations. 
Extra  Cloth  (or  Oilcloth  for  the  dissection-room),  32.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Grays  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  American  Medical  Association. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised. 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Rich.ard  C.  Norkis, 
A.M.,  ^LD.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in 
calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject  tlioroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner." — Medical  Record,  New  York. 

PENROSE'S  DISEASES  OF  WOMEN. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of  Pennsyl- 
vania; Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  529  pages,  handsomely  illustrated.     Cloth,  S3. 50  net. 

"I  shall  value  very  highly  the  copy  of  Penrose's  'Diseases  of  Women'  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book."— Howard  A.  Kelly, 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  l)e  commended  without  reserve,  not  only  to  the  student  but  to  the 
general  practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained 
with  absolute  clearness." — Therapeutic  Gazette. 


Medical  Publications  of  W,  B.  Saunders.  19 

POWELL'S  DISEASES  OF  CHILDREN.     Second  Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Physician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.      Cloth,  ^i.oo;   interleaved  for  notes,  $1.25. 

[See  Saunders''  Qtiestioii-Compends,  page  21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates." — 
American  Practitioner  and  Neivs. 

PRINGLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
J.  J.  Pringle,  M.B.,  F.R.C.P. ,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.      Complete  in  12  Parts.      Price  per  Part,  $3.00. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and  will 
be  of  great  value  to  all  studying  dermatology." — Stephen  Mackenzie,  M.D.  (London 
Hospital). 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency, 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 

"  The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 
"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full -page  colored  plates.      Cloth,  ^1.25  net. 

"  Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Journal. 

RONTGEN  RAYS. 

Archives  of  the  Rontgen  Ray  (Formerly  Archives  of  Clinical 
Skiagraphy).  Edited  by  Sydney  Rowland,  M.A.,  M.R.C.S.,  and 
W.  S.  Hedley,  M.D.,  M.R.C.S.  A  series  of  collotype  illustrations, 
with  descriptive  text,  illustrating  the  applications  of  the  new  photo- 
graphy to  Medicine  and  Surgery.  Price  per  Part,  $1.00.  Now  ready! 
Vol.  I.,  Parts  I.  to  IV.;  Vol.  II.,  Part  I. 


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THE  REASON  WHY. 


riiey  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5^7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kejH  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  ■will  be   mailed  on  receipt  of  price  fsee  next  page  for  List). 


Oaunders^  Question-Compend  Series* 

Price,  Cloth,  $1,00  per  copy,  except  when  otherwise  noted. 


"Where   the  work   of  preparing  students'  manuals   is   to   end  we   cannot   say,  but   the 
Saunders  Series,  in  our  opinion,  bears  off  the  palm  at  present."— AVw  y'oik  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.   Hare,  M.D.      Third   edition, 

revised  and  enlarged.      ($l.oo  net.) 

2.  ESSENTIALS   OF   SURGERY.     By  Edward  Martin,  M.D.      Sixth  edition, 

revised,  with  an  Appendix  on  Antiseptic  Surgery. 

3.  ESSENTIALS   OF   ANATOMY.      By  Charles   B.    Nancrede,   M.D.     Fifth 

edition,  with  an  Appendix. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.D.      Fourth  edition,  revised,  with  an  Appendix. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF   PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Arm  and  Semplf:,  M.D. 

7.  ESSENTIALS  OF   MATERIA  MEDICA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.     Fourth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE    OF    MEDICINE.      By   Henry   Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formtdre,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.      (Double  number,  ^2.00.) 

10.  ESSENTIALS  OF  QYN/ECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Third  edition,  revised  and  enlarged.      (3l.oo  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D.,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.  D.      Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By   Lawrence  Wolff, 

M.D.     Colored  "VoGEL  Scale."      (75  cents.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

M.D.      ($1.50  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  M.D.      Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      ($1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


Saunders' 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners. 


^T^HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press.  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  w^ritten  and  exhaustive  in  detail,  w^ithout 
being  encumbered  with  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
v^ants  to  kno\v,  they  will  prove  of  inestimable  value ;  to  the  former  they  v^ill  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  work  worthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders^  New  Series  of  Manuals* 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital ; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.     Cloth,  ^1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta,  M.D.,  Clini- 
cal Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the 
Philadelphia  Hospital,  etc.      1S8  illustrations  and  13  plates.      (Double  number.) 

New  and  enlarged  edition  in  preparation. 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTION=WRITING.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.      Cloth,  ^1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.     Illustrated.     Cloth,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  $1.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.      Profusely  illustrated.      (Double  number.)      Cloth,  ^2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary ;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
(Double  number.)     Cloth,  ^2.50  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.      Beautifully  illustrated.      (Double  Number.)     Cloth,  $2.50  net. 

MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.  Profusely  illustrated.  (Double  number.)  Cloth, 
^2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London ;  and  Arthur  E. 
Giles,  M.D.,  B.Sc.  Lond. ,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     (Double  number.)     Cloth,  ^2.50  net. 


VOLUMES  IN  PREPARATION. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor  of  Laryn- 
gology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia  ;  Consulting  Laryngolo- 
gist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadel- 
phia Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College.  Philadelphia;  Pathologist  to  the  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  works 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


24  Medical  Publications  of  W.  B.  Saunders. 


SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Sauxdby, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  $--5°  "^t. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended.'" — British  Medical  Journal. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.     Fourth  Edition, 
Revised. 

By  William  ^L  Powell,  ]\LD.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1750 
formulae  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulae  and  Doses  for  Hypo- 
dermic Medication.  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 
$1.75  net. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  u.seful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAUNDERS'  POCKET  MEDICAL  LEXICON.  Fourth  Edition, 
Revised. 
A  Dictionary  of  Terms  and  Words  used  in  Medicine  and 
Surgery.  By  John  M.  Keating,  JNLD.,  Fellow  of  the  College  of 
Physicians  of  Philadelphia;  Editor  of  the  *' Cyclopaedia  of  Diseases 
of  Children,"  etc.;  Author  of  the  "New  Pronouncing  Dictionary  of 
Medicine;"  and  Henry  Hamilton,  Author  of  "A  New  Translation 
of  Virgil's  ^neid  into  English  Verse;"  Co- Author  of  the  "New 
Pronouncing  Dictionary  of  Medicine."  32mo,  280  pages.  Cloth, 
75  cents;  Leather  Tucks,  31.00. 

"  Remarkably  accurate  in  terminolog)",  accentuation,  and  definition." — Journal  of  the 
American  Medical  Association . 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  31.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends^  pa^ge  21.] 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 


Medical  Publications  of  W.  B.  Saunders.  25 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

Essentials  of   Legal   Medicine,  Toxicology,  and  Hygiene.     By 

C.  E.  Armand  Semple,  B.  A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lond., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  2 1 2  pages ;  130  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders^  Question- Compe?ids,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.   E. 

Armand  Semple,  B.A. ,  M.B.  Cantab.,  M.R. C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.     Crown  octavo, 
174  pages;  illustrated.      Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Saundets'  Question- Compends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  GENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.      Cloth,  $3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Repoi'ter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Senn,  M.D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery  in  Rush  Medical  College,  Chicago.     Cloth,  $2.00. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it. " — Nezv  York  Medical  Times. 

SENN'S  TUMORS. 

Pathology  and  Surgical  Treatment  of   Tumors.     By  N.   Senn, 

M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Octavo  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Cloth,  $6.00  net; 
Half  Morocco,  $7.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  isliandsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical  Association. 


26  Medical  Publications  of  W.  B.  Saunders. 


SHAW'S  NERVOUS  DISEASES  AND  INSANITY.     Third  Edition, 

Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  i86  pages;  48  original  illustrations.  Cloth, 
31.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"Clearly  and  intelligently  written."' — Boston  Medical  and  Surgical  Journal. 
"  There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American 
Medico- Surgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.     31.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessarj',  the  diet 
lists  are  printed  in  full.      Kormulse  for  the  preparation  of  diluents  and  foods  are  appended. 

STELWAGON'S  DISEASES  of  THE  SKIN.  Third  Edition,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  270  pages;  86  illustrations.  Cloth,  31.00  net;  inter- 
leaved for  notes,  31.25  net. 

[See  Saunders'  Question-Compends,  page  21.] 
"  The  best  students  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register. 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.     By  Alfred  Stengel,  M.D.,  Physician 

to  the  Philadelphia  Hospital ;  Professor  of  Clinical  Medicine  in  the 
Woman's  Medical  College  ;  Physician  to  the  Children's  Hospital ; 
late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc.  In 
Preparation. 

STEVENS'   MATERIA    MEDICA    AND    THERAPEUTICS.      Second 
Edition,   Revised. 
A  Manual  of   Materia   Medica   and  Therapeutics.      By  A.  A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Physical  Diagnosis  in  the  University  of  Pennsylvania;  Demonstrator 
of  Pathology  in  the  Woman's  Medical  College  of  Philadelphia.  Post- 
octavo,  445  pages.     Cloth,  32- 25. 

'*  The  author  has  faithfully  presented  modem  therapeutics  in  a  comprehensive  work, 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice." — University  Aledical  ^Magazine. 


Medical  Publications  of  W.  B.  Saunders.  27 

STEVENS'  PRACTICE  OF  MEDICINE.  Fourth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.M., 
M.D.,  Lecturer  on  Terminology  and  Instructor  in  Pliysical  Diagnosis 
in  the  University  of  Pennsylvania ;  Demonstrator  of  Pathology  in 
the  Woman's  Medical  College  of  Philadelphia.  Specially  intended 
for  students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  511  pages;  illustrated.      Flexible  leather,  $2.50. 

"The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  may  be  found  also  an  excellent  reminder  for  the  busy  physician." — Buffalo 
Medicai  Journal. 

STEWART'S  PHYSIOLOGY. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
D.Sc,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  800  pages;  278  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  ^3.50  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Aledical Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
^i.oo  ;  interleaved  for  notes,  ^1.25. 

[See  Saunders^  Question- Compends,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 
knowledge  of  their  subject." — Aledical  Neros. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice. 

By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass.;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  ^1.75  net. 

"  There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially 
endorsed  by  a  medical  journal  as  can  this  one." — Therapeutic  Gazette. 

"  This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — America}t  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the 
assurance  of  benefit." — Ohio  Medical  Journal. 


28  Medical  Publications  of  W.  B.  Saunders, 


SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond. ,  F.R.C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.      Cloth,  32.50  net. 

' '  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical 
public. " — British  Medical  Jonrtial. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  0/  the 
American  Medical  Association. 

THOMAS'S  DIET  LISTS  AND  SICK=ROOM  DIETARY. 

Diet  Lists  and  Sick=Room  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home  ;  Assistant  Visiting  Physician 
to  the  Kings  County  Hospital.      Cloth,  $1.50.     Send  for  sample  sheet. 

"  The  idea  is  good,  and  the  lists  are  copious." — London  Lancet. 

"Its  practical  usefulness  places  it  among  the  requirements  of  every  practitioner." — 
Chicago  Medical  Recorder. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of   Prescription=Writing.       By   E.    Q. 

Thorxtox,  M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Philadelphia.      334  pages,  illustrated.      Cloth,  $1.25  net. 

"Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  Willia.m  W.  Van  Valzah,  M.D. , 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  Vork  Polyclinic;  and  J.  Douclas  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  Vork  Polyclinic.  Octavo  volume  of  670 
pages.      Cloth,  53. 50  net. 

VIERORDT'S  MEDICAL  DIAGNOSIS.  Third  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  second  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.M.,  M.D.  Handsome  royal  octavo  volume 
of  700  pages;  178  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  S4.00  net;  Sheep  or  Half  Morocco,  S500  net;  Half  Russia, 
$5.50  net. 

"  A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every  busy 
practitioner  who  will  consult  it." — C.  A.  LiNDSLEY,  M.D.,  Professor  of  the  Theory  and 
Practice  of  Aledicine,   Yale  University. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned ;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatory  and  digestive  apparatus  and 
nervous  system- are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Medical 
Alagazine. 


Medical  Publications  of  W.  B.  Saunders.  29 

WARREN'S  SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Department  Harvard 
University;  Surgeon  to  the  Massachusetts  (reneral  Hospital,  etc. 
Handsome  octavo  vokime  of  832  pages;  136  relief  and  lithographic 
illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which  were 
drawn  by  William  J.  Kaula  from  original  specimens.  Cloth,  $6.00 
net;   Half  Morocco,  $7.00  net. 

"There  is  the  work  of  Dr.  Warren,  which  I  think  is  the  most' creditable  book  on 
Surgical  Pathology,  and  the  most  beautiful  medical  illustration  of  the  bookmaker's  art,  that 
has  ever  been  issued  from  the  American  press." — Dr.  Roswell  Park,  in  the  Harvard 
Graduate  Magazine. 

"  The  handsomest  specimen  of  bookmaking  that  has  ever  been  issued  from  the  American 
medical  press." — A))ierican  Journal  of  the  Medical  Sciences. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WEST'S  NURSING. 

An  American  Text=Book  of  Nursing.  By  American  Teachers. 
Edited  by  Roberta  M.  West,  late  Superintendent  of  Nurses  in  the 
Hospital  of  the  University  of  Pennsylvania.      In  Preparation. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents. 

[See  Saunders'   Question- Compends,  page   21.] 
"  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fourth  Edition,  Revised. 

Essentials    of    Medical    Chemistry,    Organic    and    Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College, 
Philadelphia,  etc.  Crown  octavo,  218  pages.  Cloth,  ^i.oo;  inter- 
leaved for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistiy. " — Pharmaceutical  Era. 


CLASSIFIED    LIST 


Medical  Publications 


W.  B.  SAUNDERS, 

925  Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  9 
Haynes — A  Manual  of  Anatomy,  .  .  .  13 
Heisler — A  Texi-Book  of  Embryology,  13 
Nancrede — Essentials  of  Anatomy,  .  .  18 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  .  .  .  iS 
Semple — Essentials   of   Pathology  and 

Morbid  Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...      6 
Crookshank — .A  Text-Book  of  Bacteri- 
ology,   10 

Frothingham — Laboratory  Guide,  .  .  il 
Mallory    and    Wright  —  Pathological 

Technique, 16 

McFarland — Pathogenic  Bacteria,    .    .    17 

CHARTS,  DIET-LISTS,  ETC. 

Griffith — Infant's  Weight  Chart,     ...  12 

Hart — Diet  in  Sickness  and  in  Health,  .  13 

Keen — Operation  Blank, 15 

Laine — Temperature  Chart,    ....  15 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Starr — Diets  for  Infants  and  Children,  .  26 
Thomas — Diet-Lists     and    Sick-Room 

Dietary, 2S 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Phys- 
ics,   7 

Wolff — Essentials  of  Medical  Chemistry,  29 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children,    .    .             3 

Griffith — Care  of  the  Baby 12 

Griffith — Infant's  Weight  Chart,  ...  12 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Powell — Essentials  of  Dis.  of  Children,  I9 

Starr — Diets  for  Infants  and  Children,  .  26 

DIAGNOSIS. 

Cohen  and  Eshner  — Essentials  of  Di- 
agnosis,    9 

Corwin — Physical  Diagnosis,      ....      9 

Macdonald — Surgical  Diagnosis  and 
Treatment,      16 

Vierordt — Medical  Diagnosis,    ....    28 

DICTIONARIES. 

Keating — Pronouncing  Dictionary,    .  .  I4 

Morten — Nurse's  Dictionary,      .    .    .  .  18 

Saunders'  Pocket  Medical  Lexicon,  .  24 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

'  of  the  Eye,  Ear,  Xose,  and  Throat,  .  3 
Casselberry — Dis.  of  Nose  and  Throat,  8 
De  Schweinitz — Diseases  of  the  Eye. .  lO 
Gleason — Essentials  of  Dis.  of  the  Ear,  il 
Jackson   and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  14 
Kyle — Diseases  of  the  Nose  and  Throat,  15 

GENITO=URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 4 

Hyde  and  Montgomery — Syphilis  and 
the  N'enereal  Diseases, I3 

Martin — Essentials  of  Minor  Surgery. 
Bandaging,  and  Venereal  Diseases,    .    16 

Saundby — Renal  and  Urinary  Diseases,  24 

Senn — Genito- Urinary.  Tuberculosis,     .    25 

GYNECOLOGY. 

American  Text- Book  of  Gynecolog}',  4 
Cragin — Essentials  of  Gynecology,  .  .  10 
Garrigues — Diseases  of  Women,  ...  11 
Long — Syllabus  of  Gynecology,  ...  15 
Penrose — Diseases  of  Women,  ....  18 
Sutton  and  Giles — Diseases  of  Women,  28 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics 3 

Butler — Text-Book  of  Materia  Medica, 

Therai^eutics  and  Pharmacology,  ...      8 

Cerna — Notes  on  the  Newer  Remedies,    8 

Griffin — Materia  Med.  and  Therapeutics,   12 

Morris  —  Essentials  of   Materia  Medica 

and  riierapeutics,  .    .  .    .    .    .    17 

Saunders*  Pocket  Medical  Formulary,  24 
Sayre  —  Essentials  of  Pharmacy,  .  .  24 
Stevens — Essentials  of  Materia  Medica 

and  Tiierapeutics, 26 

Thornton — Dose-Book  and    Manual   of 

Prescription-Writing, 28 

Warren — Surgical  Pathology  and  Ther- 
apeutics,       29 

MEDICAL   JURISPRUDENCE    AND 
TOXICOLOGY. 

An  American  Text-Book  of  Legal 
Medicine  and  Toxicology, 4 

Chapman — Medical  Jurisprudence  and 
Toxicology, 8 

Semple — Essentials  of  Legal  Medicine, 
Toxicology,  and  Hygiene, 25 


Medical  Publications  of  W.  B.  Saunders. 


31 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 7 

Chapin — Compendium  of  Insanity,  .  .  8 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 9 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 26 

NURSING. 

An  American  Text-Book  of  Nursing,  29 

Griffith— The  Care  of  the  Baby,    ...  12 

Hampton — Nursing, 12 

Hart — Diet  in  Sickness  and  in  Health,  I3 

Meigs — Feeding  in  Early  Infancy,     .    .  17 

Morten — Nurse's  Dictionary,     ....  18 

Stoney — Practical  Points  in  Nursing,    .  27 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  4 
Ashton — Essentials  of  Obstetrics,       .    .  6 
Boisliniere — Obstetric  Accidents,  Emer- 
gencies, and  Operations, 7 

Borland — Manual  of  Obstetrics,    ,    .    .  lo 

Hirst — Text-Book  of  Obstetrics,    ...  13 

Norris — Syllabus  of  Obstetrics,  ....  18 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,  5 
Mallory    and    Wright  —  Pathological 

Technique, 16 

Semple — Essentials   of    Pathology  and 

Morbid  Anatomy, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors,        25 

Stengel — Manual  of  Pathology,     ...    26 
Warren — Surgical  Pathology  and  Thera- 
peutics,    29 

PHYSIOLOGY. 

An  American  Text-Book  of  Physi- 
ology,        5 

Hare — Essentials  of  Physiology,  ...  13 
Raymond — Manual  of  Physiology,  .  .  I9 
Stewart — Manual  of  Physiology,  ...    27 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine,  ....      5 

An  American  Year-Book  of  Medicine 
and  Surgery,  6 

Anders — Text-Book  of  the  Practice  of 
Medicine, 6 

Lockwood — Manual  of  the  Practice  of 
Medicine, 15 

Morris — Essentials  of  the  Practice  of 
Medicine, 17 

Rowland  and  Hedley  —  Archives  of 
the  Roentgen  Ray, I9 

Stevens — Manual  of  the  Practice  of 
Medicine, 27 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 


Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 13 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    16 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    19 

Stelwagon — Essentials  of  Diseases  of 
the  Skin, 26 

SURGERY. 

An  American  Text-Book  of  Surgery,  5 
An  American  Year-Book  of  Medicine 

and  Surgery, 6 

Beck — Manual  of  Surgical  Asepsis,  .    .  7 

DaCosta — Manual  of  Surgery,  ....  10 

Keen — Operation  Blank 15 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 15 

Macdonald — Surgical    Diagnosis    and 

Treatment, 16 

Martin — Essentials    of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,     .  16 

Martin — Essentials  of  Surgery,  ....  16 

Moore — Orthopedic  Surgery, 17 

Pye — Elementary  Bandaging  and  Surgi- 
cal Dressing, 19 

Rowland    and    Hedley  — Archives  of 

the  Roentgen  Ray, 19 

Senn — Genito-Urinary  Tuberculosis,      .  25 

Senn— Syllabus  of  Surgery, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

W^arren — Surgical  Pathology  and  Ther- 
apeutics,        29 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  24 
Wolff — Essentials    of    Examination    of 
Urine, 29 

MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Bot- 
any,      7 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 11 

Gross — Autobiography  of  Samuel  D. 
Gross, 12 

Keating — How  to  Examine  for  Life 
Insurance, 14 

Keen — Surgical  Complications  and  Se- 
quels of  Typhoid  Fever, 15 

Rowland  and  Hedley — Archives  of 
the  Roentgen  Ray, 19 

Saunders'  New  Series  of  Manuals,    22,  23 

Saunders'  Pocket  Medical  Formulary,  .    24 

Saunders'  Question-Compends,    .    .  20,  21 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Stewart  and  Lawrance — Essentials  of 
Medical  Electricity, 27 

Thornton — Dose-Book  and  Manual  of 
Prescription-Writing,    . 28 

Van  Valzah  and  Nisbet — Diseases  of 
the  Stomach, 28 


In  Preparation  for  Early  Publication. 


AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAR,  NOSE, 
AND  THROAT. 

Edited  by  G.  E.  DE  SCHWEINITZ,  M.D. ,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  Philadelphia;  and  B.  Alexander  Randall,  M.D.,  Professor 
of  Diseases  of  the  Ear  in  the  University  of  Pennsylvania  and  in  the  Philadelphia 
Polyclinic. 

AN  AMERICAN  TEXT-BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy  in  the  University  of  Pennsylvania;  and  David  Riesman,  M.D. ,  Demon- 
strator of  Pathological  Histology  in  the  University  of  Pennsylvania. 

PETERSON  AND  HAINES'  LEGAL  MEDICINE  AND  TOXICOLOGY. 

An  American  Text=Book  of  Legal  Medicine  and   Toxicology.     Edited  by 

•  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental  Diseases  in  the  Woman's 
Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York  ;  and  Walter  S.  Haines,  M.D.,  Professor  of 
Chemistr}-,  Pharmacy,  and  Toxicology  in  Rush  Medical  College,  Chicago. 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.  By  Alfred  Stengel,  M.D.,  Physician  to  the  Phila- 
delphia Hospital ;  Professor  of  Clinical  Medicine  in  the  Woman's  Medical  Col- 
leg'e ;  Physician  to  the  Children's  Hospital ;  late  Pathologist  to  the  German  Hospital, 
Philadelphia,  etc. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 

Nervous  and  Mental  Diseases.  Dy  Archibald  Church,  M.D. ,  Professor  of 
Mental  Diseases  and  Medical  Jurisprudence  in  the  Northwestern  University  Medical 
School,  Chicago;  and  Frederick  Peterson,  M.D. ,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic,  Nervous 
Department,  College  of  Physicians  and  Surgeons,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Professor  of 
Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D.,  Clinical  Pro- 
fessor of  I.arvngolotry  and  Khinology,  Jefterson  Medical  College,  Philadelphia;  Con- 
sulting Laryngologist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist 
to  the  Philade'phia  Orthopedic  Hospital  and  Inlirmary  for  Nervous  Diseases,  etc. 

HIRST'S  OBSTETRICS. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D.,  Professor  of 
Obstetrics  in  the  University  of  Pennsylvania. 

WEST'S  NURSING. 

An  American  Text=Book  of  Nursing.  By  American  Teachers.  Edited  by 
Roberta  M.  West,  Late  Superintendent  of  Nurses  in  the  Hospital  of  the  University 
of  Pennsylvania. 


1                   Date  Due                     | 

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Pn.NTEo  IN  U.S.*              CAT.    NO.    24    161                Sr 

"nj^??^  .  <^'^^' 


UCSOUIHERI 


D  000  165  138  9 


WI  300 
V28Ud 
1898 
Van  Valzah,  Williaa  W. 
Diseases  of  the  stomach 


IVIEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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